CORE Metadata, citation and similar papers at core.ac.uk Provided by Saint Louis University School of Law Research: Scholarship Commons Saint Louis University Law Journal Volume 48 Number 1 Unequal Treatment: Racial and Ethnic Article 9 Disparities in Health Care (Fall 2003) 12-1-2003 A History of Health Care for the Indigent in St. Louis: 1904–2001 Daniel R. Berg, M.D. Follow this and additional works at: https://scholarship.law.slu.edu/lj Part of the Law Commons Recommended Citation Daniel R. Berg, M.D., A History of Health Care for the Indigent in St. Louis: 1904–2001, 48 St. Louis U. L.J. (2003). Available at: https://scholarship.law.slu.edu/lj/vol48/iss1/9 This Article is brought to you for free and open access by Scholarship Commons. It has been accepted for inclusion in Saint Louis University Law Journal by an authorized editor of Scholarship Commons. For more information, please contact Susie Lee. SAINT LOUIS UNIVERSITY SCHOOL OF LAW A HISTORY OF HEALTH CARE FOR THE INDIGENT IN ST. LOUIS: 1904–2001 DANIEL R. BERG, M.D.* I. INTRODUCTION The city of St. Louis assumes the responsibility to “provide for the support, maintenance and care of children and sick, aged or insane poor persons and paupers.”1 Despite this bold statement in the City Charter, infant mortality in north St. Louis is still more than double the United States’ average, and higher than many Third World countries.2 In fact, there is an entire underclass within the city that suffers from health outcomes more comparable to the Third World countries than to their neighbors in west St. Louis County. The ideals of the city founders have been lost in a sea of time. Inadequate health care for the poor is not a new phenomenon, and one can trace wildly disparate health care expenditures and outcomes between white and black and rich and poor throughout St. Louis history. To understand how St. Louis arrived at its current situation, one must look at how local financial interests, racism and political wrangling have interplayed with national trends in health care delivery and finance over the last century. * This paper is the product of a research project conducted during the author’s internal medicine residency under the supervision of Will Ross, M.D., Associate Dean and Director of the Office of Diversity at the Washington University School of Medicine. Dr. Berg is a lifetime St. Louisan and founder of Health and Environmental Justice St. Louis. He is currently serving as an internist with the Public Health Service at Gallup Indian Medical Center in Gallup, New Mexico. He can be reached at [email protected]. 1. ST. LOUIS CITY CHARTER art. I, § 1, cl. 31. 2. See 1 CITY OF ST. LOUIS DEP’T OF HEALTH PLANNING AND INFORMATION, PUBLIC HEALTH: UNDERSTANDING OUR NEEDS 69 (1999) [hereinafter CITY OF ST. LOUIS DEP’T OF HEALTH PLANNING AND INFORMATION]. According to the report, infant mortality in the 63120 zip code is 18.1 per 1000 live births. For comparison, in the year 2000, infant mortality rates were 7.5 per 1000 live births in the entire United States, 10.0 per 1000 in Costa Rica, and 7.5 per 1000 in Cuba. WORLD HEALTH ORG. DEP’T OF CHILD AND ADOLESCENT HEALTH AND DEV., INFANT AND UNDER FIVE MORTALITY RATES BY WHO REGION: YEAR 2000, at http://www.who.int/child-adolescent- health/OVERVIEW/CHILD_HEALTH/Mortality_Rates_00.pdf (last modified July 16, 2003). 191 SAINT LOUIS UNIVERSITY SCHOOL OF LAW 192 SAINT LOUIS UNIVERSITY LAW JOURNAL [Vol. 48:191 II. PUBLIC HEALTH CARE IN THE EARLY PART OF THE TWENTIETH CENTURY: 1904–1937 At the turn of the twentieth century, cities, not the federal government, provided the health safety net for the poor. The cities possessed ample resources, and at the time the federal government possessed relatively few. The St. Louis Health Department tackled its responsibility through a range of activities including water testing, quarantining people with smallpox and tuberculosis, conducting sanitation inspections, providing a “poor house” for the homeless, and making provisions for public hospitals. At the beginning of the Twentieth Century, the city owned a female hospital, an insane asylum, a quarantine hospital, and a traditional “City Hospital.” Medicine and medical care during the early part of the Twentieth Century were extraordinarily different than today. In general, people were sicker, lived in worse conditions, and had less access to care (which was usually ineffective). The citizens of St. Louis suffered from many diseases now rarely (or never) encountered such as smallpox, typhoid, syphilitic paresis, and scrofula.3 Doctors also performed procedures that appear strange now—such as pneumothorax for tuberculosis, insulin-induced seizures for depression, and malarial infection for syphilis.4 St. Louis City Hospital #1 (City Hospital #1) began operations in 1846, but it was destroyed in a cyclone in 1896.5 After it was rebuilt in 1904 at Lafayette Avenue and 14th Street on the city’s near-south side, the hospital symbolized the city’s commitment to health care through its impressive architecture and massive size. During the first half of the Twentieth Century, it developed into a substantial hospital complex with an academic medical program, active laboratories, an adjacent mental health hospital, and other health-related facilities on the same campus. Medical school graduates during the first third of the century considered the residency program at City Hospital #1 one of the most prestigious in the country. Medical students, interns, and residents gained practical experience with a large volume of ill patients under the guidance of respected attending physicians from both Washington University School of Medicine and the Saint 3. See, e.g., CITY OF ST. LOUIS HEALTH DEP’T, TWENTY-FOURTH ANNUAL REPORT OF THE HEALTH COMM’R 380-81 (1901) (Max C. Starkloff, M.D., Commissioner); CITY OF ST. LOUIS HEALTH DEP’T, THIRTY-THIRD ANNUAL REPORT OF THE HEALTH COMM’R 56 (1910) (H. Wheeler Bond, M.D., Commissioner). 4. Interview with Dr. Joseph Levitt, M.D., former resident at City Hospital #1, in St. Louis, Mo. (Dec. 10, 2001). 5. Lorraine Kee, Future of Old City Hospital Site Hinges on Development Prospects, ST. LOUIS POST–DISPATCH, May 18, 1999, at B1. SAINT LOUIS UNIVERSITY SCHOOL OF LAW 2003] A HISTORY OF HEALTH CARE FOR THE INDIGENT IN ST. LOUIS 193 Louis University Medical School. Interns and residents lived in the hospital itself and dedicated themselves completely to patient care and education.6 Several factors contributed to the success of the public hospitals in the 1910s–1930s. First, the city was relatively wealthy and health care was inexpensive. The population base and the more affluent had not yet migrated to the county suburbs. Also, relatively few people had access to insurance or social welfare. As such, a well-run public hospital appealed to the middle class as well as the lower class. No organized voting constituency objected to the large open wards, the inconsistent food quality, and the unequal funding between public and private institutions.7 But as the United States became more prosperous and socially aware through the 1950s and 1960s, the inequities of the public hospitals became less and less palatable. III. RACIAL DISCRIMINATION Despite these public institutions, health outcomes for African-Americans and Caucasians differed dramatically in the early part of the Twentieth Century. While wealthy and indigent Caucasians also experienced very different health outcomes, it is much easier to trace disparities between the races because the Health Department kept separate statistics on the health outcomes of white and black people throughout the entire Twentieth Century. For example, in 1901, African-Americans in St. Louis died of tuberculosis at a rate more than three times higher than whites.8 Most of these disparities arose from differences in living conditions related to poverty and segregation; however, the public institutions also gave different treatment based upon race. City Hospital #1 was kept strictly segregated, with African-Americans in the rear part of the second and third floors. This arrangement of having separate wards for African-Americans within a predominantly white hospital provided adequate space when the local African-American population was relatively small; however, as southern blacks migrated to St. Louis and other northern cities, the African-American population swelled. In 1900, according to the United States Census, there were 575,238 people in the city of whom 6. Interview with Dr. Ralph Berg, M.D., Intern and Resident at City Hospital #1 from 1922–1926, in St. Louis, Mo. (Oct. 7, 2002). 7. See HARRY F. DOWLING, CITY HOSPITALS: THE UNDERCARE OF THE UNDERPRIVILEGED 77 (1982). An illustration of this unequal funding shows that in 1915, Bay View Asylum Public Hospital in Baltimore spent $0.72 per patient, per day while Johns Hopkins private ward spent $4.70. In Boston, Boston City spent $2.34 per patient, per day while Massachusetts General Private Hospital spent $3.31. In New York, Bellevue Public Hospital spent $1.63 per patient, per day compared to the $7.99 spent by Presbyterian Hospital on its private patients. Id. 8. See CITY OF ST. LOUIS HEALTH DEP’T, TWENTY-FOURTH ANNUAL REPORT OF THE HEALTH COMM’R, supra note 3, at 380-81. Mortality from tuberculosis among white St. Louisans was 1.5 per 1000 in 1901, while among blacks, it was 4.8 per 1000. Id. SAINT LOUIS UNIVERSITY SCHOOL OF LAW 194 SAINT LOUIS UNIVERSITY LAW JOURNAL [Vol. 48:191 only 35,516 (6%) were African-American. By 1920, 69,854 of the 772,897 people in the city were African-Americans (9%).9 This growth represents a near doubling of the black population in twenty years.