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79 iv. Geographical Distribution of minority residents In the preceding chapter I described the process by means of which Black Americans gained access to hospitals as patients and also as professional staff, beginning first in racially segregated settings such as the veterans’ administration hospital in Tuskegee, Alabama, and the Harlem Hospital Center. Both of these developments came in the aftermath of World War I as a result of demands of the Black community. In part 2 I outline the entry of African Americans into mainstream hospitals , which occurred in the context of sweeping social changes in American social structure following World War II. Among the major driving forces for these changes were the democratization of higher education, the increased wealth of new science and technology, and the breaking down of social class and religious barriers, which had limited the size of the American middle class. College enrollments in the nation increased from two million in 1946 to eight million in 1970 (Ludmerer 1999, 188). While Black Americans enjoyed some of these gains through the GI Bill of Rights, they were still largely handicapped by being confined to a segregated rather than mainstream educational pathway; even mortgages guaranteed by the GI Bill still largely confined them to segregated neighborhoods with inferior public schools. No longer did a bachelor’s degree reflect special knowledge; graduate students in those same 1946 to 1970 years increased from 120,000 to 900,000. Similarly, an M.D. degree giving one the right to practice general medicine after a year of rotating internship was no longer a sign of professional competence. Beginning in the late 1940s and swiftly setting a new pace, postgraduate training leading to specialty board certificates became the new standard of competence for physicians. Hospitals had increased in number, supported by governmental funding, and teaching hospitals offering approved residency training positions increased from 5,796 in 1940 to 46,258 in 1970 (Ludmerer 1999, 181–83). The American public was demanding more medical care, and of a higher quality, especially when financial barriers to care were significantly removed in the late 1960s by the passage of Medicare and Medicaid governmental funding, both of which generously provided not only for patient care but financed residency training programs as well. Between 1956 and 1980 the number of United States medical schools increased from 84 to 127, enabling first-year enrollments to double, going from 8,000 to 16,590. Medical school enrollments and annual graduation rates could not keep up with the residency training positions offered: in 1958 U.S. medical schools graduated 6,861 students, but 12,325 residency training positions were offered by teaching hospitals that year. A special Surgeon General’s consultant group in 1959 advised that the nation’s health could not be protected unless medical schools increased their annual graduates from 7,400 to 11,000 by 1975. Federal funding made this possible, and the targeted increase was met. In all of these vastly expanded opportunities Black Americans were only minimal beneficiaries because color caste confined them to segregated settings . Slowly the color line was melting, as shown by the new way that public and private hospitals desperate for staff had begun to hire Black nurses. A signal event occurred in 1951, when the National Association of Colored Graduate Nurses, which had been founded in 1908, disbanded. Leaders in that organization and in the predominantly White American Nursing Association agreed that all nurses should belong to a single national group, and that the thirty or so Black nursing schools also could go out of business because almost all of the 1,152 nursing schools nationwide were already accepting qualified applicants regardless of color (Morais 1969, 199; D. B. Smith 1999, 42–44). The medical establishment was slower to change, but significant changes occurred for some previously excluded groups. With more resident training positions and more medical students entering and graduating , quotas against Jews and Catholics, at that time excluded minorities, disappeared (Ludmerer (1999, 206–7), but in the 1950s and 1960s no positive steps were taken to recruit women or members of other minority groups. It was not until affirmative action programs began in 1970 that women and minorities were admitted to medical schools in greater numbers and therefore could gain acceptance to postgraduate training teaching hospitals. The shortfall of medical school graduates led to a huge and sudden influx of foreign medical graduates (FMGs): from 1950 to 1959 alone foreign medical graduates in the nation’s residency training programs...

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