Abstract
The Great Migration, the movement of 6,000,000 black Americans from the South to the great urban centers of the eastern seaboard, the industrial Midwest, and West Coast port cities from roughly 1915-1970, was one of the defining demographic events in American history. It dwarfed the 100,000 49ers who swarmed westward in search of gold, the incarceration of 110,000 Japanese to concentration camps in the American interior during World War II, and the 300,000 Okies who escaped the Dust Bowl to California. In the words of writer Isabel Wilkerson, “[It] swept a good portion of all the black people alive in the United States at the time into a river that carried them to all points north and west.”
Blacks crammed into urban districts rife with crime and communicable disease, subjecting them to risks of death far higher than their proportion of the population. Without access to adequate inpatient hospital facilities, they received care in public hospitals run by hospital staffs that excluded black physicians from their membership and medical schools that refused admission to black students. The untenable health station of Black America was one of the leading causes of the civil rights movement of the 1950s and 1960s, activism that succeeded in integrating the hospitals and medical schools by federal acts passed in 1964 and 1965 that transformed American medicine.
From Segregated South to Segregated North
Two award-winning books written on The Great Migration provide facts for the section that follows. The Promised Land, published in 1993, was written by Nicholas Lemann, former dean of the school of journalism at Columbia University. 1 A more recent treatment, The Warmth of Other Suns, authored in 2010 by Isabel Wilkerson of Boston University, features the oral histories of those who made the trek northward. 2
The Great Migration was both an escape from intolerable conditions in the South and the pull of economic opportunity in the North. Under the strictures of Jim Crow laws rural tenant farmers toiled under sharecropping, a system that exploited their labor to nearly the same degree as slavery. They were locked in poverty, never able to own land or accumulate wealth. Gasoline-powered farm machinery in the first half of the 20th century that began with the invention of the tractor in 1890, made animal-powered cultivation and manual harvesting obsolete. Denied education and the right to vote, subject to lynch mobs and race riots where their attackers were never arrested nor brought to justice, blacks escaped northward to freedom. 1
It began as a trickle with the end of Reconstruction in 1877 and increased to a constant stream as Jim Crow took hold in the last decades of the 19th century. The first wave came during World War I when European immigration nearly halted. Deprived of cheap labor slaughterhouses, foundries, and factories in the north hired agents who scoured the South recruiting young black men. “With nothing to lose,” upwards of 550,000 blacks left the South during the decade of WWI. 2
Millions followed. Rather than abating with the end of the war, as southern planters and labor brokers had hoped, the migration only increased, nearly doubling in the 1920s to 903,000. The Great Depression decreased the flow somewhat (480,000 in the 1930s), but the floodgates opened as America mobilized during World War II. Workers of both races toiled in shipyards on both coasts and repurposed automobile and chemical plants churning out fighters, ships, artillery, and munitions. The decade of the 1940s saw 1.6 million leave the South, of which 1.2 million entered the military.
The two-front world war indiscriminately pulled men of military age, white and black, into the US armed forces. At first black recruits were relegated to labor and service units. As warfare intensified the demand for men in arms led to the formation of all-black fighting battalions such as the 761st Tank Battalion that fought with Gen. Patton in the Battle of the Bulge and fighter groups such as the famed Tuskegee Airmen. 3
When the war ended, many black Americans chose not to return to the South but left for good: 1.4 million in the 1950s, and another million during the murderous last stand against civil rights in the 1960s. 2
All cities that were major terminuses for black migration were transformed. Chicago was a prime example. Lemann wrote
Reporters, academics, performers, and liberal clergymen would occasionally make field trips to the Illinois Central station to look out in wonder at the sea of humanity in the waiting room.
1
At one point 2300 blacks entered the city every week. In 1940 the city’s black population was 278,000; by 1960 it was 813,000. The numbers certainly were underestimates. Many blacks avoided contact with any civil authority, including census takers, wary that one might actually be a bounty hunter hired by landlords, bailiffs, and creditors from back home.
In Chicago’s South Side families crammed into tenements that only provided the rudiments of shelter and plumbing. Apartments were subdivided into kitchenettes, single-room domiciles that shared a common bathroom. Four to five families might live in one kitchenette. Day workers slept in rotation on a shared bed. Decent hygiene was impossible under such crowded conditions. 2
In factories their wages far lower than those paid to whites. Entire categories of jobs were excluded to them. Lemann notes
There were no black drivers of yellow cabs, no black salesclerks at the great department stores in the Loop, no black linemen at Illinois Bell, no black bus drivers, no black policemen or firemen except at the stations in the black belt, and no blacks in the building trades unions.
1
The only work open to them were as janitors, laundry workers, garbagemen, and domestics in affluent neighborhoods. Blacks were mired in menial labor with no hope of promotion, enhancement of their skills, and quality of their jobs. The temptation for dissolution was strong, with gambling, prostitution, alcohol, and drugs readily accessible. 1
With their accustomed routines and status in society at risk, white America responded with racism and xenophobia. The turmoil reached a climax with the bloody East St. Louis race riot of 1917 and the Red Summer race riots, 24 in number that swept the country in 1919. 4
White European immigrants that could work their way out of poverty and educate their offspring into better-paying occupations and professions escaped southward from the worst of the South Side neighborhoods. Members of the black middle class who had the means to do the same, however, were barred from doing so through restrictive covenants that carried the force of law. The result was a densely populated black urban district, “packed to the bursting point.” 1
Districts of newly arrived immigrants were always rough and dominated by teenage gangs. One concept of the sociology of immigration posits that juvenile delinquency is an inevitable stage in the assimilation process for any new incoming group. Legendary Chicago mayor and political boss Richard Daley was a member of a South Side Irish street gang in his youth.
Law enforcement in black neighborhoods was casual because Chicago police considered black-on-black crime not considered worth solving. In such an environment black gangs thrived. Lemann wrote
Emerging as they did from the largest and poorest of all Chicago’s immigrant groups, they became the roughest and most extensive gangs the city had ever known.
1
Black teen gangs proliferated in the late 1950s and early 1960s. Turf lines were drawn as rival groups exerted their dominance. Trying to go about their lives without attracting attention or being caught in the crossfire of warring tribes, innocent residents were subject to extortion and robbery, notably in the elevator lobbies of the massive high rise housing projects constructed by the Chicago Housing Authority in the 1950s. Parents tried desperately to keep their children from being recruited into the local gang or its rival. Once a boy reached age 11 or 12, joining a gang was an irresistible rite of passage.
The borders between black and white territories were scenes of bitter racial violence. In 1919 a black youth drowned at a beach after being chased by a gang of whites, an event that sparked a week of rioting that left 23 blacks and 15 whites dead and hundreds injured. In 1947 the opening of an integrated housing project in a white neighborhood precipitated a riot. When a black family moved into a white Chicago neighborhood in 1949, a mob of 2000 whites gathered that night and threw rocks and firebombs. 1
To address the filth and squalor of urban tenements, now entirely black, the Federal Housing Act of 1949 financed the construction of public housing. Under Mayor Daley the Chicago Housing Authority siphoned federal funds into the coffers of trade and construction unions. Placing housing projects on vacant land in white neighborhoods was politically impossible. Instead, the Chicago Housing Authority razed entire black neighborhoods and constructed massive high-rise buildings in districts that already were all black and poor, hemmed in by uncrossable expressways. They became hellscapes ruled by gangs and beset by gang warfare, rife with crime, and without decent schools and community services. Segregation in northern cities was as unjust and brutal as that in the rural South. 1
Black Medical Ghetto
Infectious Disease
David McBride, professor of African American history at Penn State University, wrote on epidemics among urban blacks in America. 5 Urban slums and social disjunction led to epidemics of tuberculosis and venereal disease that threatened all strata of society. Today we recognize epidemic disease as consequences of overcrowding, poverty, and a failure of public hygiene; at the turn of the 19th century, they were signs of racial inferiority and moral depravity.
Impossible to ignore was the wide health discrepancy between blacks and whites. In 1900 the death rate for Blacks were 29.6 per 1000 population, compared with 17.3 for whites. Communicable diseases were rampant, with the annual death rates for Blacks far exceeding those for whites in tuberculosis (485 versus 174 deaths per 100,000, respectively), pneumonia (356 and 185), typhoid (68 and 32), and malaria (63 and 7). 5
Rates of maternal and infant deaths were far higher among Blacks in Northern cities. In 1922 the national infant mortality rates for Blacks were 110 deaths under age 1 per 1000 live births; for whites it was 73. The differences were more dramatic in cities: for Baltimore the numbers were 191 and 78, respectively; in Kansas City they were 155 and 78. 5
Dispensaries, Almshouses, and Black-Owned Proprietary Hospitals
For basic care during the 19th century the urban poor depended on dispensaries, a concept imported from late 18th century England specifically to keep the needy from filling hospitals, treating at home until a patient either recovered or died. Run on a shoestring and dependent on both private and municipal contributions, dispensaries were where apothecaries provided medications and house physicians performed simple procedures, such as tooth extractions. 6
Families in city slums could ill afford to have one of its members sick and require the attendance of an adult or older child. Almshouses were caretakers of last resort for the dispossessed, and its sickrooms were the forerunners of the public hospital. The Friends Almshouse, established in 1713, evolved into the Philadelphia General Hospital. The first permanent almshouse in New York City, established in 1736, became Bellevue Hospital. 7 They had primarily a custodial mission, isolating those with infectious disease and housing those with incurable conditions, with confinements that could last for months to years. 8
Most private hospitals prohibited the admission of Blacks. A few operated by churches and the city admitted Blacks in segregated wards, often in basements, vacant rooms, and abandoned wards. 9 The Pennsylvania Hospital kept a small building separate from the main wing for Blacks and patients with venereal disease. 7
The few Black doctors in country in the late 19th century had no place to admit their patients who needed inpatient care and no place to perform surgery. They established their own hospitals that also served as training sites for first Black nursing students, then later internships for medical graduates.
Venessa Northington Gamble, professor of medical humanities at George Washington University, wrote a complete history of the Black hospitals in America. 9 The first was Provident Hospital in Chicago, organized by Daniel Hale Williams (1856-1931) in 1891, followed by Frederick Douglass Hospital in Philadelphia, organized by Nathan Mossell (1856-1946) in 1895. By 1920, 118 Black hospitals were in operation, a miniscule number that never could satisfy the immense demand for healthcare of the urban black population. All of them lacked money, the major reason they failed. 9
Public Hospitals
In the late 19th century, technical advances in surgery and bacteriology led to the development of a hospital-based professional staff of doctors and nurses, skilled in increasingly complex surgical operations and inpatient treatment regimens. 6 The flood of immigrants from Europe and the American South coincided with the rise of hospitals in the urban north. Bellevue became the largest public hospital in the country. With large concentrations of patients with advanced disease, public hospitals became centers of clinical research and training of physicians. 7
Black patients dominated the censuses at urban public hospitals. The facilities were under the control of white administrators and staffed by entirely white physician and nursing staffs. A 1930 survey found that the Philadelphia General Hospital, where the inpatient population was one-half Black, had an entirely white staff of 200 physicians, 50 residents and interns, and 600 graduate and student nurses. Harlem Hospital evolved into an entirely Black hospital during the interwar period yet had an entirely white professional staff. 5 With large censuses of poor black patients who had no alternatives for medical care, public hospitals became places where white interns and residents acquired clinical experience through practicing medicine and surgery under minimal or no supervision.
By the end of World War II, the National Medical Association, the largest and most prominent black professional society, and the NAACP declared that, in Gamble’s words, “a segregated healthcare system resulted in the delivery of inferior medical care to Black Americans.” In essence, she wrote, “a poorly financed Black medical ghetto existed.” 9
In both North and South hospitals remained segregated, unequal, and inadequate, and training facilities that remained closed to Black nurses and doctors. The only way to assure full access to hospitals and medical schools would be their complete integration, which was accomplished by the passage of the Civil Rights Act of 1964 and the Social Security Amendments of 1965 that created Medicare.