No Medical Justification: Segregation and Civil Rights in Alabama’s Psychiatric Hospitals, 1952–1972

In October 1963, President John F. Kennedy signed into law the Mental Retardation and Community Mental Health Centers Construction Act (also known as the Community Mental Health Act, or CMHA), which required states to downsize their existing, overcrowded psychiatric hospitals and offered new federal funds for the construction of community-based centers. To qualify, each state was required to submit a Comprehensive Mental Health Plan. The author of the Alabama plan, the newly hired state health officer Dr. Ira Lee Myers, made a number of frank admissions. “The anti-federalism, the crippling preoccupation with race, the defensiveness inflamed by defeat, poverty and resentment of the efforts to change the people’s value system,” he wrote, “have flared again.” In addition to the baleful influence of those he called “anti–mental health extremists,” Myers claimed that “[t]hese attitudes have not only slowed our state’s progress in the quantity and quality of mental health services, training and research, but have cast a shadow over the planning process itself. Reluctance to accept federal funds and resistance to the concept of planning had to be overcome before the actual job of organizing to plan and study could begin.”¹

At the time of the plan’s formulation, Alabama operated racially segregated health facilities, but with the passage of the Civil Rights Act in 1964, the state faced increasing pressure to desegregate. Rather than actively pursue integration, which was also necessary to qualify for new construction funds, Alabama took the federal government to court over what it claimed was its right to maintain separate facilities for Black and white psychiatric patients.² The case was overseen in federal district court by Judge Frank M. Johnson Jr., a fierce upholder of civil rights law in Alabama, despite the opposition of Governor George Wallace and others, and an exemplar of the power of federal reach and of presidential appointments in undermining segregation in the states.³ On February 11, 1969, Johnson handed down a decision in answer to “a rather straightforward problem”: racial segregation in the state’s psychiatric hospitals was illegal and unconstitutional.⁴

This article examines the struggles that culminated in Johnson’s final decision in 1969. In the fight to maintain segregated psychiatric facilities, southern segregationists employed many of the same arguments used in their fight to maintain segregated schools: the idea that the federal government should stay out of state affairs; the belief that racial unrest was the result of northern outside agitators; and the claim that African American culture was inherently deprived or destructive.⁵ Yet when it came to desegregating medical facilities, southern segregationists also benefited from latent racist assumptions and ideas that had long held sway in modern American medicine and psychiatry. Since the late eighteenth century, American medical practitioners had been constructing definitions of difference between white and Black bodies that positioned African Americans as inherently lacking in intelligence and emotional complexity.⁶ Racist ideas about Black deviance and the so-called childlike psyche of African Americans were regularly employed to justify disparities both in accommodations and in treatment and were central to the foundation of America’s psychiatric hospitals.⁷ For the white public, these ideas found expression in fears of physical contact and miscegenation, complicated by the intimacy of medical settings. In such spaces, bodies were necessarily vulnerable and exposed, and the need for care meant that segregation could not always be so neatly maintained.⁸

Activists seeking to end segregation in Alabama’s psychiatric facilities thus needed to challenge not only the racist ideas prominent among white Alabamians but also the latent racism of psychiatric thinking itself. The history of the struggle for integration in Alabama’s psychiatric facilities reveals the complex ways that local communities related to these institutions as places of both employment and medical care and situates such institutions within larger debates about segregation that raged after the passing of the Civil Rights Act. Alabama’s politicians and bureaucrats were willing to use even the mentally ill for electoral gain and thus unexpectedly positioned psychiatric hospitals as a site of political combat in the policy battle for civil rights in that state.⁹ This battle highlights the importance of the antiracist work undertaken by organizations such as the National Association for the Advancement of Colored People (NAACP) and its Legal Defense and Educational Fund (LDF) and demonstrates the close collaboration these organizations had with grassroots activists. In Alabama, John L. LeFlore was central to the campaign for the desegregation of psychiatric facilities, and his papers reveal a long relationship with both the NAACP and the LDF and with local health-care workers and patients’ families in seeking to end discrimination.¹⁰ In the fight to force compliance with the Civil Rights Act, activists such as LeFlore revealed the atrocious conditions that prevailed in psychiatric hospitals and the falsity of medical justifications for segregation. American psychiatric hospitals in the 1960s were not pleasant places for anyone. For African Americans in the Deep South, however, these institutions acted as a powerful and often deadly reminder of the long reach of Jim Crow, where white supremacists and segregationists used the mentally ill as political playthings.

This article first situates psychiatric hospitals in the United States in the contexts of a move toward community-based mental health services and of the medical civil rights movement. Next, it examines the way the government of Alabama responded to the federal mandate to integrate and elucidates the political to-and-fro of that process. Documents from the Alabama state archives expose the duplicitous behavior of Governor George Wallace and others and the public attitudes that supported segregationist politicians. Yet medical workers and patients’ families joined with John LeFlore and the LDF to highlight the continuing discrimination, eventually bringing a class action against the state of Alabama. The grassroots activism and class action complemented the federal government’s twin strategies to enforce civil rights compliance using federal law and Medicaid and Medicare funding. Finally, the article analyzes the process and impact of the LDF’s class action, which formally ended segregation and provided important information for Judge Johnson to continue his efforts to eliminate racial discrimination in Alabama. However, I argue, these strategies have not been enough to bring about equality for African Americans in the mental health system. This system, which now intersects with mass incarceration, is still undermined by racist attitudes and a lack of funding, contributing to the overrepresentation of Black Americans with mental health issues in prisons.

Psychiatric hospitals do not often figure in the history of civil rights, and yet they were home to many thousands of Black southerners.¹¹ After World War II, repeated investigations and exposés found southern psychiatric hospitals to be of substandard quality for all patients. In this, they were no different from their northern counterparts, yet they suffered a more marked lack of funding, a much larger patient population, and a lack of engagement with the latest psychiatric thought. As Albert Deutsch wrote in his famous The Shame of the States (1948) about Georgia’s Central State Hospital at Milledgeville (Deutsch did not visit Alabama), “If I found shameful conditions at Milledgeville, they differed only in degree, not in kind, from those found in most American mental hospitals. The shame is not Georgia’s alone, nor the South’s, but the nation’s.” Yet Deutsch’s assessment made no specific consideration of conditions for Black patients, which in the South were complicated by the long history of segregation and overt racial violence.¹²

Public knowledge of the shameful state of the nation’s “snake pits” was at an all-time high after World War II, but rarely did that concern extend to Black patients.¹³ Hospital segregation had been reinforced in 1946 by the passing of the Hospital Survey and Construction Act, better known as the Hill-Burton Act, which supplied significant federal funds for new construction but also allowed for continued racial segregation provided that “services of like quality” were developed.¹⁴ This “separate but equal” ideal was rarely upheld. In a series of reports throughout the 1950s, Dr. W. Montague Cobb, editor of the Journal of the National Medical Association, cataloged the ways that hospitals operating across the South failed to provide adequate services in either separate or combined facilities, expressing concern for the future of African American health care.¹⁵ Cobb and his colleagues knew that putting an end to discrimination in hospitals would require legal action. It would take major policy change before such legal action was possible, however.¹⁶

The years 1963–1965 were transformative for institutional mental health care in the United States, owing to a combination of legal action and federal legislation. In November 1963, the LDF won its most significant health-care case to that date, Simkins v. Moses H. Cone Memorial Hospital, in North Carolina, making the argument that “separate but equal” hospital accommodations were unconstitutional under the Fifth and Fourteenth Amendments.¹⁷ At the same time, the Community Mental Health Act, passed in October 1963, provided matching block grants to states for the construction of community-based facilities in a deliberate attempt to force the downsizing of large state hospitals. In order to qualify for CMHA funds, each state needed to bring its mental health services under a “single State agency” and to submit a comprehensive community mental health plan to the National Institute of Mental Health (NIMH).¹⁸ For many southern states, these plans revealed the inherently separate and unequal provision of mental health services and the reliance on large hospitals. Alabama’s survey of existing resources and plans for the future ran to hundreds of pages, spelling out in clear detail the dearth of trained personnel and facilities and the vast disparity between private and public services.¹⁹

In Alabama, public services for adults and children were confined to two institutions: Bryce Hospital in Tuscaloosa and Searcy Hospital in Mount Vernon. Searcy housed more than 2,500 African American adults, and Bryce was home to more than 5,000 people in 1963. The grounds at Bryce also included the Partlow Hospital and School for Children and Bryce Treatment Center II, a “farm colony” operating at Northport and home to about four hundred African American men and women. In the required state report, Ira Myers noted that Alabama had relied too heavily on these two state facilities, both of which were little more than custodial—merely holding places for the state’s unwanted people—and hampered by understaffing and overcrowding. He admitted that there was too little state appropriation ($3.00 per diem compared with a national average of $5.75) and little public willingness to increase taxes.²⁰

Myers submitted this report to the NIMH in September 1965, knowing that Title VI of the Civil Rights Act mandated that no facility receiving federal funds could discriminate on the grounds of race. Title VI also contained two provisions to compel change: voluntary compliance and judicial enforcement. Southern hospitals had not generally pursued voluntary compliance: three years after the Simkins case, the LDF noted that little had changed in the way that patients were housed, and Black doctors across the South still had no admitting privileges. Title VI should have given fuel to the civil rights activists within the federal government, but the U.S. Department of Health, Education, and Welfare (HEW) was itself slow to enforce the law.²¹

The situation was even more complicated in relation to state-funded psychiatric hospitals. For example, on May 5, 1965, Edward J. Rourke, assistant general counsel at HEW, made a note that he had orally advised Robert M. Nash, the civil rights officer in the Public Health Service (PHS), that “if State mental health institutions receive no Federal or matching funds directly or indirectly under any continuing State program, the desegregation of such institutions would not be required, nor need be reported as an area of noncompliance by the State.” However, states would be required to file HEW Form 441, “Assurance of Compliance,” declaring nondiscrimination in any research or project grants, which could provide some leverage.²² As far as the NIMH was concerned, nondiscrimination should have also applied ipso facto to facilities built with federal community mental health money, but attempts to retroactively apply nondiscrimination requirements to NIMH construction grants were complicated by legal technicalities.²³ Because southern states like Mississippi, Alabama, and Louisiana had applied for almost no federal funding for state psychiatric services, and were not rushing to apply for CMHA money either, there was no real leverage with which to compel change in these states until the passing of the Social Security Amendments (Medicare/Medicaid) of 1965.²⁴

The Medicare and Medicaid program is largely credited as the most significant policy for enforcing the integration of hospitals, as it promised large amounts of monetary support to states for indigent and elder care. While psychiatric hospitals were excluded from Medicare and Medicaid funding because the federal government had no desire to reinforce those institutions, funds were made available to poor individuals and for the creation of nursing homes. These two measures gave states the means to move patients out of large hospitals and into smaller facilities or services, which the law now required to be racially integrated. The process for monitoring this compliance was carried out by the Civil Rights Unit within HEW and consisted of the “Assurance of Compliance” Form 441 submitted by each state. These assurances were largely accepted at face value and were challenged only if a victim of discrimination submitted a complaint. At that point, HEW could instigate an administrative review. If a state were found to not be in compliance, then HEW could recommend that existing and future funds be paused or withheld. Faced with the burden of an administrative hearing and the threat of withdrawal of funds, most states voluntarily submitted their forms to signal their compliance, but even with this carrot-and-stick approach, some facilities in some states continued to hold out.²⁵

In order to bring these outliers into compliance, in February 1966 HEW created a special office within its Civil Rights Unit called the Office of Equal Health Opportunity (OEHO). PHS civil rights officer Robert Nash became its first director, and he was joined by a number of legal activists as investigators. This small office was created hastily and temporarily and was provided limited resources for the inspection of state facilities for civil rights compliance.²⁶ In June 1966 OEHO inspectors arrived in Alabama. Administrators of the state’s mental health system were not surprised, because they had already been working to actively sidestep the mandate to integrate mental health facilities.²⁷

The campaign for medical integration largely coincided with the governorship of George Wallace, who was no stranger to the fight against civil rights and a master at manipulating public perception for political expediency. His approach to desegregating psychiatric hospitals was no different from his response to educational integration or any other matter related to racial equality. As per usual, he relied on denial, obfuscation, and public blustering to resist segregation.²⁸ His initial strategy with psychiatric hospitals was to wait and see: on June 4, 1965, Wallace sent the superintendent of Alabama’s state hospitals, James S. Tarwater, a memo thanking him for their fruitful meeting the previous day. In reference to “the matter we discussed,” Wallace made a vague suggestion about “the transfer of patients” and “waiting to see what the reaction will be.” This was one of the very few times that Tarwater ever met with Governor Wallace, and he would not have done so over a trifle. It seems safe to assume that they discussed integration and that Wallace decided to say nothing publicly about it, although he was fully aware that a transfer of patients was about to happen.²⁹

Meanwhile, Tarwater was under siege from HEW and the Public Health Service regional office in Atlanta. As the director of the Alabama Mental Health Board, which oversaw all mental health and psychiatric facilities in the state, Tarwater was asked to prove these services’ compliance with the Civil Rights Act. In July 1965 he sent a series of memos to various facility and clinic directors asking them to verify their compliance in writing.³⁰ The process of establishing written compliance confirmed to the Alabama Mental Health Board that the state hospitals were clearly not compliant. Tarwater was thus under constant pressure from the PHS to do more than simply submit a form. William Page, the director of the PHS in Atlanta, reminded Tarwater that HEW would not hesitate to take legal action if desegregation were not actively pursued.³¹ The Alabama Mental Health Board was still not in a hurry to comply, and it was not until January 7, 1967, that Tarwater wrote to the HEW regional office with a plan for compliance.³²

On March 4, 1966, Superintendent Tarwater advised hospital administrators of his plan to begin integration by transferring thirty Black women from Searcy Hospital to Bryce and, in exchange, moving thirty white women to Searcy. It is likely that this was the “transfer of patients” referred to in Wallace’s memo from some nine months earlier, although it was not explicitly acknowledged. The Montgomery Advertiser ran a story on March 15 with the headline, “Mental Facilities Desegregated,” in which it reported, “One of the few remaining areas of public racial discrimination in Alabama tumbled Monday with [the] announcement that state mental facilities are being desegregated by July 1.”³³ While Alabama Mental Health Board member Dr. Robert Parker admitted that the move “was a bitter pill to take,” he also made clear that the threatened withdrawal of federal funds had compelled him and his colleagues to “vote unanimously for compliance with the Civil Rights Act of 1964.”³⁴

Governor Wallace was notably quiet on the issue. He made no public comment until late April 1966, when relatives of a white woman named Pearl H. Stokes, who had been transferred to Searcy, organized a petition for her release, which they sent directly to Alabama senator Lister Hill. When this petition made the news, Wallace claimed ignorance of the patient transfer and sent a telegram to all members of the Alabama Mental Health Board on April 26, 1966, demanding that they meet with him the next day. Given the communication with Tarwater from almost a year earlier, we can assume that in fact Wallace knew full well that the transfer was scheduled and had done nothing about it until the Stokes family went public registering their dissatisfaction with the move. At that point, Wallace used false outrage to capitalize on popular support against integration. At the meeting with the board, Wallace threatened that if the patients were not moved back immediately, he would have the highway patrol intervene.³⁵ The board complied, and the patients were returned. As a result of the reversal, Tarwater was forced to report to the regional office of the Public Health Service in June that the state of Alabama would not be taking any more formal steps toward compliance with Title VI of the Civil Rights Act.³⁶

Indeed, the white public response was swift and demonstrated the general support for segregation. In April 1966 Wallace received a copy of an angry letter from J. S. Haddock. Haddock complained that the patient transfer was “the most damnable thing possible for poor, innocent, helpless people, especially a Southern Educated Woman, who has suffered the misfortune of a sick mind … and now she is to be placed with negroes. You are sentencing her to death.” Haddock drew on pervasive ideas among whites about the danger that Black men posed to the so-called innocence of white women and about the fear of bodily contact, miscegenation, and the invasion of intimate (white) spaces by Black bodies. Haddock also placed his concerns in the context of anti-federalism, arguing, “And now, we are to be taken over by and ruled by johnson, Negroes and Communists.” The rhetorical linking of progressive U.S. president Lyndon B. Johnson and civil rights with communism was a familiar trope in the discourse of anti-integration groups, and it would have made perfect sense to Wallace. Equally powerful was Haddock’s reminder to Wallace of his vote, which he expected to be in service of “states’ rights”: “It appears to me, we are being force[d] to surrender, or sell our birth rights, for Federal Aid Money? We may suffer for a while, but any and every sacrifice, will prove beneficial.” Haddock expressed the same attitudes that Dr. Ira Myers had lamented in the Alabama community mental health plan, and such outrage undercut the state’s willingness to subscribe to any federal grant scheme that would in fact have benefited all Alabamians.³⁷

Wallace replied to such letters in very careful language that reinforced the ideas of his supporters but lacked any overt racial prejudice. By the late 1960s, segregationist language was shifting to a more race-neutral tone, and as historian Dan T. Carter has argued, Wallace knew when to be outspoken and when to be circumspect.³⁸ When writing letters that could prove difficult to explain away later, Wallace was not inflammatory; rather, he drew on what he claimed were medical justifications for segregation as what was best for patients. There is no evidence that Wallace had read any of the psychiatric or psychological literature that had posited this justification, but the frequency and ease with which he used this defense demonstrates how widespread and well understood these thoughts were.³⁹ The strategy provided not only a “scientific” rationale for segregation but also a social one, in the context of medical facilities where the intimate closeness of bodies was cause for segregationist concern.

For example, Wallace reiterated this point in a letter to Eugene Threadgill: “it has always been my contention that the integration of mental patients would be very harmful to the patients themselves.” Wallace was no medical expert, but he did have access to members of a mental health board who were not keen to overturn existing social relations in facilities where people had impaired memory, cognition, and self-control. Wallace’s real concern, however, was the rhetoric of states’ rights, as he told Threadgill: “this is just another area where the Federal government is trying to impose its will upon the rights of the sovereign people of a state.”⁴⁰

Some Alabamians, however, were aware that this insistence on segregation would lead to increased funding pressures, and they told Wallace so. Alpha Corkle, a white woman, sent Wallace a petition signed by more than thirty people from Opelika. Corkle’s husband was a patient at Bryce, and she understood that the refusal to integrate meant a loss of federal funds. “Since all patients benefit from the funds,” she wrote, “I would like to appeal to you to change this situation. I am sure the patients would rather associate with Negroes than have the lack of attention they need.”⁴¹ Corkle exemplified the concerns of white moderates who favored practical accommodations rather than continued resistance because they also stood to gain—what Derrick Bell has called “interest-convergence.”⁴² Wallace assured her that no funds had been lost, and he again used the rhetoric of medical benefit to justify his actions, writing, “It is my understanding that some eminent psychologists would testify that it is very detrimental to the health and welfare of patients for them to be integrated.”⁴³ Wallace gave no source for his information, but in these responses he was drawing on older psychiatric rhetoric that argued that segregation was necessary because the mentally ill, especially those with any kind of dementia, were liable to act out racially motivated violence. In this thinking, the fear was almost always for the white male patient, who may be the subject of (however righteous) Black anger, or the white female patient, who may be the subject of the mythical Black sexual avarice.⁴⁴ The fact that these ideas had historically been supported in medical and psychiatric discourse gave Wallace’s claims some form of legitimacy. Even though they were becoming outdated and had been challenged through the education integration campaigns, these ideas still held sway in the white popular consciousness and proved hard to dislodge.⁴⁵

Not everyone in Alabama’s mental health system believed that segregation was necessary, however. An anonymous employee from Searcy Hospital opposed the integration reversal, insisting that there had been no problems with the original integration attempt, from either patients or staff, and that to move people again would simply add more stress to already emotionally vulnerable people. The employee called out Wallace’s blatant opportunism and accused the governor of adding unnecessary fuel to the fire of Alabama’s resistance to integration: “The action you have taken,” the writer stated, “will only slow down the eventual complete integration and place on public display hundreds of mentally ill patients as well as endangering their lives and the lives of already underpaid, overworked employees. Trouble is already expected this weekend in the form of a demonstration. You know what this involves. If you think placing lives of incompetent persons in danger is the only way to get votes and makes you rest better at night, I feel sorry for you.” The Searcy staff member signed the letter, “One of the underpaid, overworked employees that really enjoys the work.”⁴⁶ The writer made clear that the only danger to patients was the extreme violence of white supremacists. These fears proved well founded, and they provided the grounds for activists both within and outside the government to finally build a legal case for desegregation.

While state officials were prevaricating about compliance with the Civil Rights Act, grassroots activists and patients’ families were already agitating for change. John L. LeFlore in Mobile was central to this activity. LeFlore was an important figure in the history of civil rights, and Mobile was an important site for workers’ rights. From his early days as a U.S. Postal Service employee and as the longtime secretary of the Mobile branch of the NAACP and its unofficial successor, the Non-Partisan Voters League (NPVL), LeFlore had been deeply concerned with the importance of employment opportunity and equality under the law for voters and workers.⁴⁷ As part of his work with the NPVL, LeFlore was aware of conditions for workers at Searcy Hospital, a mere thirty miles north of Mobile. In June 1965 he wrote to Luther Terry, the surgeon general of the Public Health Service, to complain of continued “stubborn policies of racial segregation affecting both patients and employees” at Searcy. Moreover, LeFlore pointed out, abhorrent practices were in place, such as “patients from the Searcy Hospital are alleged to be compelled to go to Tuscaloosa by bus to work on a farm operated by the white hospital.”⁴⁸ He requested information about the funding status of Bryce and Searcy Hospitals, since their racial segregation put them in breach of the Civil Rights Act. Terry forwarded the letter to Robert Nash, who informed LeFlore that the PHS head office in Washington did not keep that kind of information about individual hospitals, but that he could find out from the director of the regional office in Atlanta, to whom he was forwarding LeFlore’s letter. “Incidentally,” Nash added, “complaints have been recorded by others against these two hospitals and they will be investigated as soon as time permits.”⁴⁹

In July, LeFlore received an answer to his questions from Carl Harper, the acting regional director of the PHS in Atlanta, that laid the groundwork for further legal action. Bryce Hospital, LeFlore learned, was in receipt of federal funds. While Searcy was not, it could be seen as part of the same statewide mental health program. “Since the [Alabama Mental Health] Board has received Federal financial assistance for Bryce Hospital, it would appear that Title VI would be applicable to both,” Harper wrote.⁵⁰

At the same time, conditions for patients at Bryce and Searcy were becoming clearer through the investigations of law student Henry Stiles, who was working in Mobile with LeFlore as part of the Law Students Civil Rights Research Council. In July 1965, Stiles informed Ruth Adams at the LDF of a series of complaints from workers and relatives of patients at Searcy, who reported that “the conditions there are appalling to us.”⁵¹ Stiles and LeFlore had been collecting information and signatures for a petition, which they sent to James M. Quigley, the assistant secretary of HEW, Michael Meltsner of the Legal Defense Fund, and Dr. Harry S. Rowe, the physician in charge of Searcy Hospital.⁵² In this petition the signatories invoked their rights as citizens and taxpayers to lay out four main demands: the desegregation of all facilities and accommodations; the elimination of discriminatory employment practices (including segregated work spaces and unequal conditions); the employment “of properly qualified Negro doctors, nurses, technicians, clerks, receptionists, bookkeepers or other personnel”; and “the indiscriminate admittance of patients to the Bryce Hospital and/or Searcy Hospital, without regard to race or color.” The petition included a thorough listing of recent legal cases, such as Simkins v. Cone Memorial Hospital and two cases from Florida, that addressed racial segregation in southern hospitals, as well as references to the Fourteenth Amendment and the relevant sections of the Civil Rights Act. The petitioners demanded that Alabama’s psychiatric hospitals “eliminate, within the next 60 days, all racial distinctions and discrimination which deny to any person or citizen equal services, rights and privileges at the said hospitals.”⁵³ LeFlore knew precisely what the U.S. Constitution provided to African Americans, and he intended to claim his community’s full rights of citizenship.

LeFlore could not have been surprised, however, that he received no response other than Rowe’s claim that it was Superintendent Tarwater’s decision about who was appointed to work in the hospitals.⁵⁴ But this silence was not the end of the issue for LeFlore. Over the next few months and into 1966, he wrote repeatedly to James Quigley at HEW, reminding him about the petition and reiterating that the Civil Rights Act gave HEW the capacity to withhold federal assistance due to noncompliance with Title VI. LeFlore rebuked Quigley for the department’s inaction, and he demanded that HEW move toward withdrawing federal funds “for the operation of all Alabama mental hospitals.”⁵⁵ In his communications with state and federal administrators, LeFlore made little reference to the conditions for patients, apart from the overall objection to their segregation. He knew that the withdrawal of federal funds from Searcy would make no difference to conditions there—as it was not in receipt of any—but he believed that the threat of withdrawal from Bryce, the well-known white hospital, might spur the state, and public, to action.

Documenting conditions for psychiatric patients in the past is a notoriously difficult enterprise given recent legislation under the Health Information Portability and Accountability Act (HIPAA), which has eradicated the patient voice from the official record. The LDF collection at the Library of Congress does not contain any material related to this situation with Alabama, and one potentially interesting file named “Psychiatric Ward Patients, 1957–1959” is restricted and currently unavailable.⁵⁶ Most of the surviving information about conditions eventually became part of the class action against the Alabama state mental health system and is housed with the U.S. District Court Records at the National Archives at Atlanta. However, LeFlore’s files also contain handwritten notes focused on segregation’s impact on the patient population. For example, LeFlore detailed a kind of patient-leasing system, where “both Negro men and women are transferred to Bryce Hospital (Tuscaloosa) and Northport for farming … . Negroes stay on farm at Northport, some of whom are transported by bus or truck to Bryce, then returned to Northport each night.” The notes also documented that white employees were able to take Black patients home to work in their houses and return them to the hospital at the end of the day.⁵⁷ Farms and manual labor were not uncommon in psychiatric institutions—the idea of work as therapy built on a long tradition of “moral treatment” where occupation was believed to be therapeutic.⁵⁸ But in the South, these practices lingered long after they had been eradicated elsewhere, serving as powerful symbols of the prevailing social order.⁵⁹ At Bryce and Searcy, most of the labor was performed by Black patients in the laundries, kitchen, stables, and farms, saving the hospitals vast sums and supplementing meager diets. These practices were little more than convict leasing repackaged. Reports from relatives also detailed Black female patients at Searcy being forced to fill and cart wheelbarrows of coal from the pile to the kitchen, outgoing mail being censored or restricted, incoming mail being stolen, and patients forced to leave their own wards and wait outdoors in all weather for the communal dining hall.⁶⁰

Stiles and LeFlore also gathered numerous reports of brutality and evidence of white supremacist violence within the psychiatric hospitals. Maimie Lee Brown signed an affidavit that her son, Joe Nathan Brown Jr., “had been beaten by two white hospital employees, named Johnson and Newton … . My son took his father and me to one of the toilets and showed us welts and blisters on his left buttock which he said resulted from the two white men beating him up with a cut-off water hose. He explained that one of the men held him while the other one beat him after locking him up.” Although beatings and abuse were a common problem across all overcrowded and badly managed psychiatric institutions, Brown was in no doubt about the racial implications of this attack, which she believed “was due to strong race prejudice in view of the fact that a number of white employees of this hospital are alleged to be members of the Ku Klux Klan.” This was not mere anecdote. As Brown stated, white employees of the hospital had in fact been arrested just the previous week “after participating in a Klan rally at Mt. Vernon and allegedly shooting into the house of a Negro woman and attempting to burn down her house.”⁶¹

Throughout 1966, LeFlore worked closely with Conrad K. Harper at the LDF head office in New York. Harper, a Howard University alumnus, was new to the LDF, having graduated from Harvard Law School in 1965. He had worked for the Civil Rights Commission during his summer internships, and the LDF was his first legal job. He was handed the Alabama case by LDF first assistant counsel Michael Meltsner after LeFlore wrote again to James Quigley at HEW and sent a copy to the LDF. “Mr. Meltsner is of the opinion the only way to obtain significant action with respect to these hospitals is to file suit,” Harper told LeFlore. To build a case from the ground up, LeFlore worked closely with Harper over the next few months to gather the needed information about the hospitals’ funding and conditions, and Harper also brought on local Alabama civil rights attorneys Orzell Billinsgley Jr. and Demetrius C. Newton to build a class of patients and employees with complaints about treatment and segregation.⁶²

At the same time, the Department of Health, Education, and Welfare was finally able to take action in Alabama. In late 1966, Special Counsel Marilyn G. Rose from the Office of Equal Health Opportunity was given the go-ahead to pursue investigations across the South, and she visited Alabama’s psychiatric hospitals to undertake a formal inspection.⁶³ In an interview conducted in 1997, Rose remembered her visit to Alabama:

While the staffing and services at Bryce as a whole were a mixed bag, services for patients at Searcy were custodial, and the general wards were horrid. There were only 5 doctors, 4 of whom were foreign (whose primary language was not English); they were not licensed in the United States and did not have credentials as psychiatrists in their native country. The fifth psychiatrist was the Administrator, obviously not conversant with modern psychiatry, and seemed to be running a southern plantation. A visit to the wards suggested to me what one might have found in the 19th century, at a time when mental patients were warehoused. The wards looked like prison cells. It was a scene out of a Kafka play.

These horrors were not confined to the adult hospitals. Rose also visited the children’s hospital in Tuscaloosa, which took both Black and white children but provided segregated services. She recalled, “We went into the day room of one ward of black patients who were profoundly mentally retarded, with physical handicaps as well; many of them were sitting and/or lying on the floor in their own excrement … . [T]here was no ward for white profoundly retarded to match the depth of despair and mistreatment as this one for blacks.”⁶⁴ Rose’s observations demonstrate that “separate but equal” was never a reality in psychiatric facilities. Instead, the practice had created a space where people could be removed from visibility entirely and where Black patients existed in a complete vacuum of approaches to treatment or care.

Exposing these conditions was not without risk. Like many civil rights activists working in Alabama at the time, Rose and her colleagues found themselves the subject of intimidation, harassment, and violence. Their visits attracted significant media attention, and they were frequently followed by Federal Bureau of Investigation agents. Witnesses in the cases were given the lawyers’ home telephone numbers after one witness had their home shot into. Two of Rose’s fellow investigators in Demopolis, Alabama, were arrested on a bogus stolen vehicle charge. Rose herself was lucky to emerge unharmed from an incident in Tuscaloosa when the lug nuts of the front wheel of her rental car were removed while it was parked outside Bryce Hospital. She remained undeterred, however, and prepared a brief for the surgeon general and HEW, articulating the many ways in which the state of Alabama’s provision of mental health services breached the Civil Rights Act.⁶⁵

The evidence Rose presented was a litany of horrors. At Bryce Hospital, four hundred African American patients were housed in Treatment Center II located eight miles from the main complex, in Ward X and the Lodge, or at the farm colony “for the purposes of performing work at or around these facilities.” Rose noted that “Ward X is particularly unsatisfactory. Negroes are housed in the old, dimly lighted building solely to work in the laundry and certain kitchen areas at Bryce. The building is adjacent to the laundry, is set off from the rest of the complex, and has a living space comprised of one large room with approximately 87 beds in close quarters. The Lodge apparently is a converted stable and is located at the rear of the main complex.” At Searcy, the 2,500 Black patients were subjected to facilities that were “very old and crowded, have no day rooms, and have bare cement floors and seating consisting of backless wooden benches. Bryce has many recreational and occupational programs and craft shops, Searcy has a television set, dominos and cards if requested, and a weekly visit from the recreation department.”⁶⁶

While the documents did not detail the specifics of treatment, they noted that no Black patients were part of the treatment funded by a large PHS grant for young men with schizophrenia, and that inferiority in treatment and care was compounded by discrimination and lack of spending in staffing. There were no Black professional staff members, such as physicians, psychologists, and nurses, at the institutions. While Bryce Hospital offered extensive nurse training for schools throughout the state, which supplied ready labor, no nurses’ training program had ever existed at or been sought for Searcy. Similarly, expenditures at Searcy were proportionately lower per patient than at Bryce, and Searcy had never applied for any Public Health Service grants. Rose also noted that “the Negro employees of the state institutions execute their functions under segregated, unequal and inferior working conditions.” These included separate dining areas and a pay system that had previously discriminated based on race but was now focused on the dubious idea of “merit.”⁶⁷ Based on these findings, Rose was given permission to issue a notice of administrative hearing.⁶⁸

The hearing took place in Washington, D.C., in the spring of 1967. Rose organized HEW’s case, calling on expert testimony from psychiatrists from New York and Baltimore, as well as local psychiatrists from the University of Alabama. She was deliberate with her witnesses, choosing people from both the North and the South who could argue against Alabama’s position that it would be medically detrimental to integrate white and Black patients and could cause riots.⁶⁹ Dr. Robert C. Hunt from the New York State Hospitals Department testified that even though he had no personal experience of working in a segregated system, he knew many “deep south psychiatrists” who had told him that they see “no clinical grounds for separating treatment of patients on racial grounds.”⁷⁰ Dr. James E. Carson from the Department of Mental Hygiene in Baltimore, a native of South Carolina, argued that he “knew what a Southerner was” but saw no reason why the South should continue its segregated practices. He related the experience of a state hospital in Maryland’s Eastern Shore that had been segregated until 1963 but now had an integrated staff and treated all patients regardless of race. Despite the institution’s location in a region of Maryland that was historically “similar to the South in cultural attitudes” and that had experienced widespread civil-rights-era strife, there were no problems within the hospital itself. Carson also pointed out that there were no counterindications from integrating patients, including among the “white patients placed in the hospital which formerly had been all Negro.” That is, the argument that white patients would be harmed in some way was groundless. Importantly, under cross-examination Carson highlighted that integration had not proved to be a barrier to recruiting staff.⁷¹ This testimony actively rebutted the state of Alabama’s arguments that cultural norms should be maintained for patient safety and that broader civil rights unrest would prove dangerous to the patients themselves.

These pro-integration arguments were reinforced by three influential psychiatrists from Alabama: Dr. Patrick H. Linton, Dr. James C. Folsom, and Dr. John Carter. Linton was an associate professor of psychiatry at the University of Alabama at Birmingham and a consultant at the Birmingham Veterans Administration (VA) Hospital. He was a progressive psychiatrist, at the vanguard of new treatments that departed from older ideas about racial difference, and he testified that there was “no therapeutic counter-indication from treating psychiatric patients in an integrated hospital.”⁷² Folsom similarly saw “no therapeutic disadvantage of integrating white and Negro patients.” Significantly, Folsom pointed out that the belief in the inferiority of Black mentality had no scientific justification. Rather, he argued, any difference in IQ between Black and white patients was “due to social-economic factors, not to race.”⁷³ These ideas were bolstered from the African American perspective by Carter’s testimony. Carter had been a psychiatrist with the Tuskegee Institute and Tuskegee VA hospital since the 1950s and was now working at the Salisbury VA hospital in North Carolina. He emphasized that the VA hospital at Tuskegee had always taken white patients and had never experienced any problems, and neither were there any issues at his current hospital. Tuskegee had employed Black staff to care for white patients “from deep south” areas, and this, too, had caused no problems.⁷⁴

The state’s argument that it was in the medical interests of all patients to maintain segregation had no support from anyone working within the system itself, including Tarwater. While Tarwater made no conclusions as to any medical benefit of segregation, he testified that the integration attempt had not, despite the protestations of some family members, caused any distress to or complaints from the patients themselves.⁷⁵ The testimony of the psychiatrists at the hearing is interesting because it ran counter to the long narrative of racial difference that had underpinned American medicine and revealed the shifts in psychiatric thinking that had begun to take place outside the South.⁷⁶ At the same time, white psychiatrists from Alabama had also been part of the segregated system they now sought to critique. Their willingness to testify and the strength of their evidence put Governor Wallace’s continual appeal to medical justification on unstable ground.

As a result of the investigation and the testimony presented, the hearing examiner, Irving Sommer, found Alabama in breach of the Civil Rights Act and ordered that all current applications for funding be suspended until compliance could be secured.⁷⁷ This was not the end of the matter for the state of Alabama, however. Rather than accept this finding and find ways to become compliant, on October 13, 1967, Alabama attorney general MacDonald Gallion filed a complaint in U.S. district court (Civil Action No. 2610-N). Instead of continuing to argue that the state was medically justified to segregate its psychiatric facilities, the complaint now rested on a charge of federal overreach.⁷⁸ Before the court had a chance to act, the LDF launched a counter-complaint. On November 17, 1967, a class action on behalf of patients (Civil Action No. 2615-N) was filed in U.S. district court by the LDF’s Jack Greenberg, Michael Meltsner, and Conrad Harper and Birmingham civil rights attorneys Orzell Billingsley and Demetrius Newton. The named plaintiffs were Loveman Marable from Bryce Hospital and Joe Nathan Brown Jr. from Searcy Hospital (the subject of the affidavit secured by LeFlore in August 1966).⁷⁹ The complaint rested on charges of blatant discrimination against and the inferiority of services for the African American patients. Their relatives were also named as Alabama taxpayers seeking to secure nondiscriminatory treatment for their relatives as patients. The complaint listed the many ways the services provided were both separate and unequal, which LeFlore and Stiles had gleaned from their own investigations supporting the evidence presented in Rose’s case at the HEW administrative hearing.⁸⁰

The two cases were filed in the Middle District of Alabama Court, Northern (Montgomery) Division, bringing them under the purview of federal judge Frank M. Johnson. Given Johnson’s record in continually upholding federal civil rights law in Alabama and forging new ground for the active protection of those rights, it may seem curious that Alabama even bothered to fight the case.⁸¹ Indeed, in a memo to the other judges, Johnson noted that both sides recognized “what they consider to be inevitable, that is, an adjudication that the statutes and present practice that require segregation on the basis of race or color is illegal and in violation of Title VI of the Civil Rights Act of 1964, and the Fourteenth Amendment to the Constitution of the United States.”⁸² However, the performative aspect of the Alabama attorney general’s political strategy dictated that the state government make a show of fighting back. The point for segregationist bureaucrats and politicians was not necessarily to win or lose but to perform Alabama’s official motto—“We dare defend our rights”—and to garner popular (white) support for doing so.⁸³

Noting that the two cases now before him dealt with the same issue, and that there were constitutional implications at stake, Johnson requested the consolidation of the cases and an identical three-judge panel for both (Frank Johnson, John C. Godbold, and T. Virgil Pittman). The case from each side was built on the testimony and evidence contained in the record of the HEW administrative proceeding, now known as Docket MCR-44.⁸⁴ There was no trial. Instead, parties prepared briefs and responses, and then representatives from each side appeared in Johnson’s chambers to argue their respective positions.⁸⁵

At no point in the court proceedings did the state of Alabama dispute the findings of either the investigation or the administrative hearing. There were no references to the rhetoric of segregation’s medical justification that had featured in George Wallace’s letter writing. Rather, the state’s complaint was a long list of ways that the federal government had not followed correct procedure (even when it had), and it demonstrated the state’s intention to fight over loopholes rather than any substantive content about racial segregation. The Alabama attorney general used language familiar to many white southerners to describe the intervention of the federal government in the affairs of Alabama, including the claim that rather than stemming from concern for patients, “the present controversy arises because, when, like the proverbial camel, HEW gets its nose under the tent in one federally supported program, it insists that all programs operated by the Alabama Mental Health Board must integrate whether or not they are supported by federal funds.”⁸⁶ This comment indicates that the state had adopted a deliberate tactic of underfunding to avoid federal surveillance and compliance. That is, if there were no federal funds being used in a particular facility (in this instance, Searcy Hospital), then, the state argued, that facility was not required to comply with Title VI. The issue for Judge Johnson was moot—some parts of the state’s mental health program did receive federal funding, so all parts of the program needed to be in compliance.⁸⁷

On February 11, 1969, the court handed down its finding in what Johnson described as “long and complicated litigation over a rather straightforward problem.” The court gave officials three months to integrate Partlow State School and Hospital and twelve months to integrate Bryce and Searcy’s patient populations, and it declared that Sections 207, 208, 209, and 248 of Title 45 of the Alabama code, which allowed and facilitated segregation, were in violation of the Fourteenth Amendment.⁸⁸ For Johnson, the cases were an important part of his own overall strategy of using judicial activism to fight desegregation in all areas in Alabama.⁸⁹ He likened his approach in these mental health cases to the way he had ruled in educational segregation: “that the patients were entitled to non-racial staff assignments.”⁹⁰ Johnson signaled his intent to do more than just rule against the state: he also demanded affirmative action in the transfer of patients, in the employment of staff, and in the pay and conditions for employees. The court also ordered that the administrators of the Alabama mental health system report to the court on their integration progress every six months until the court was satisfied.⁹¹

The fact that Johnson also presided over other mental health and civil rights cases during this time complicates our understanding of the effectiveness of this single class action in integrating mental health facilities in Alabama. The court-mandated reporting from the Marable case continued until at least 1975, even after Johnson had ruled in another extremely significant mental health case, Wyatt v. Stickney (1971), about the rights of all patients. It is possible to link the Marable case to Wyatt through an expansion of the concept of civil rights to patient (or human) rights, something that historians and Johnson himself later considered in his own assessment of the cases.⁹² However, at the time Johnson made a clear link between his affirmative action in Marable and another case about the rights of Black workers to equal pay, U.S. v. Frazer (1968).⁹³ This case, which sought to end discrimination in employment practices in federally funded grant-in-aid programs in Alabama, was pending at the same time as Johnson was considering the evidence in the Marable case. The Alabama Department of Mental Health was also a defendant in the Frazer case. Johnson saw Marable as a central case in his efforts to uphold federal civil rights law in both Frazer and Wyatt, because it “is the only decision and decree which addresses across-the-board employment, by race, by the Department of Mental Health. All of the employment issues encompassed by Marable have been subsumed in the US motion for supplemental relief in Frazer.”⁹⁴ As LeFlore had argued in his constant communication with the federal government, the issue on which the court could unequivocally rule was the integration of personnel and the eradication of unequal pay and working conditions under the Constitution and Title VI of the 1964 Civil Rights Act. By using the Marable reporting requirement, Johnson was able to continue to gather data about the employment of workers and payment practices within the mental health system and to put pressure on the state to apply for federal funds for construction, research, and training.⁹⁵ He used the same reporting system to monitor the integration of patients, and in the later Wyatt and follow-up cases, he instituted “human rights committees” to monitor the other constitutional protections afforded to patients.⁹⁶ The reports submitted to the court over the next eight years demonstrated a continued pattern of attempts at integration of patients and personnel and the failure to meet even barely minimum standards.⁹⁷

In his final ruling in Marable v. Alabama Mental Health Board, Johnson also noted, “The record reveals considerable expert medical testimony to the effect that there is no medical justification for the segregation of patients and personnel in the Alabama mental health system.” While he did reserve the right for physicians to make medical decisions that took into account “patients’ fears and delusions,” he warned the state that “[r]acial classifications are always suspect” and that medical justifications for segregation would not fare well in his court.⁹⁸ The extent to which the case led directly to integration, however, is blurred by the influence of other milestones in the care of the mentally ill. The Community Mental Health Act and Medicare, along with rulings in Wyatt and other cases about the need for minimum standards and a “right to treatment,” forced a rapid downsizing of institutional care across the United States. This “transinstitutionalization” meant that the state could shift the burdens of care to nursing homes, general hospitals, and eventually to prisons.⁹⁹

Similarly, the court finding that there was no medical justification for separate and unequal treatment based on race did not end the practice in Alabama. The idea that it was no longer acceptable to talk about racial segregation created a kind of “race-neutral” language that worked to hide continuing disparities because many mental health institutions stopped recording the race of patients entirely.¹⁰⁰ This development was reinforced by “freedom of choice” rhetoric, the same used to justify continued educational segregation. In the case of mental health, families and relatives of patients were now “free” to have patients committed to any institution, usually the one closest to home, which thereby reinforced existing geographical segregation. At the same time, the rhetoric of racial difference between the white and Black psyche found new forms of expression in the marketing of race-specific drugs dressed as science and in changing diagnostic criteria that now cast the African American man as inherently more aggressive.¹⁰¹ It was not new rhetoric but merely a repackaging of much older ideas in the history of American psychiatry and medicine.¹⁰²

None of these ideas or practices were news to African Americans themselves. They knew all too well that medical spaces were not necessarily safe ones, and that the institutions that purported to care for them were in no way exempt from the rhetorical and actual violence of white supremacy.¹⁰³ Patients, relatives, and activists approached those institutions with caution yet continued to demand their rights as citizens and taxpayers. It was through these demands that activists sought to end Jim Crow in the asylum, but the state’s fight to maintain it came at a great cost to all of Alabama’s citizens. As Dr. Myers knew all too well, the “crippling preoccupation with race” meant that more money was spent on fighting the federal government than on applying for new mental health funding. In 2021, Alabama was ranked forty-seventh in the United States for access to care, and the state continues to fight court battles over its lack of mental health funding for prisoners.¹⁰⁴ Bryce and Searcy Hospitals in their original forms no longer exist, but the poor and people of color in Alabama still find themselves at the mercy of separate and unequal mental health care, as white supremacy is remade beyond the asylum walls.