Medicare Hospital Certification Program Interview: Dr. Norman Robbins

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GM: I'm Gordon Margolin. Today is April 5th, 2021 and I'm about to facilitate an oral history with Dr. Norman Robbins, one of the four individual faculty members from NIH who undertook the role of investigating some of the aspects of medical care of Black citizens in the South, back  in 1966. We're going to talk about all of Dr. Robbins’ experiences and I think you'll find them terribly interesting. This venture occurred just before the onset of the Medicare program and the federal government was very interested in making sure that everything was in place when the program went into effect. This history is being recorded on Zoom as we are still in the Covid-19 pandemic. This is the best we'll be able to do in case there are some difficulties with the recording.

Good morning Dr. Robbins. Thank you so much for being willing to review both the history of 1966 and your life with us at the same time.

NR: Thank you.

GM: Let's start out by telling me about your early life, where you were raised, your schooling, how you selected medicine as a career.

NR: I grew up in New York City and lived at various times in four of the five boroughs. I was born in Brooklyn, raised in Queens, and went to school in Manhattan and the Bronx. In relation  to what we're going to be talking about, I think my mother was my first role model of volunteerism. During the second World War she volunteered in the Women's Auxiliary Corps. I remember her coming home with a gas mask on her belt because New York was waiting for an attack from Nazi submarines. Later she volunteered as a foreign student organizer at the New School, and so on for the rest of her life. Even in her last years, staying at an assisted living facility, she wrote biographies of staff members in the local newsletter because she felt the residents didn't appreciate the lives of the people that were serving them. So she was a major influence -- looking at situations, figuring out what to do, and volunteering. My father also volunteered, doing magic shows at nursing homes after he retired.

As for higher education, I went to Columbia College where I majored in Oriental studies, but then started thinking about psychiatry, so I went to medical school, at Harvard, and got interested in research. Nonetheless, I did a year of internship at Bellevue hospital in New York and that was a fascinating experience -- my first exposure to treating low-income patients, and making do with limited facilities. It was quite a challenge but was very satisfying. After another year of residency, I felt I needed more science education, so I got a Ph.D. at Rockefeller University. That  brings us up to NIH.

GM: What year did you graduate medical school?

NR: In ‘59.

GM: Then when did you come to NIH? What were your assignments there?

NR: I joined up as a researcher in 1965 in Phil Nelson's neurophysiology lab. There were some 10 or 12 independent Public Health Service people like myself, mostly doing separate research projects in neurophysiology.

GM: So you were there a year before this volunteer opportunity came along. How did it happen to come  into play that you decided to go to the Southern states?

NR: In early 1966 Phil Nelson, the head of my lab, asked me if I were interested in going down South to integrate hospitals. One of the reasons he picked me was because I was the only member of the lab who was single at the time; the rest all had young families and so I could be dispensed with, as it were. I also did not really understand what I was getting into— I thought it sounded interesting, so I said, “Okay, I'll do it.” That's how I ended up in Jackson, Mississippi.

GM: The four of you who went were all Public Health Service officers. Is that correct?

NR: That's right, yes.

GM: It wasn't because you belonged to the Medical Committee for Human Rights, is it?

NR: No, it wasn't. Later, after I got back from Mississippi, I joined up but mostly on other issues that they were dealing with. It was strictly because Secretary [John] Gardner, the Secretary of HEW, had sent out a very broad request for volunteers when they realized early in 1966 that they had this looming deadline when Medicare was going to come into effect, on July 1, 1966. And there were still literally thousands of hospitals that might be not in compliance for desegregation. So they had an enormous job and very little time, leading Secretary Gardner to send out this broad appeal for volunteers. And that’s how it filtered down in my case to the head of my laboratory.

GM: Basically, this program going to the South was a federal program or federally sponsored program.

NR: Absolutely. But what made it interesting is that it didn’t matter  what your background was—for example, they sent this appeal to Social Security people and many of them volunteered. All together I learned that about 700 people from across federal departments volunteered.   It was a strictly off-the-cuff kind of effort, but it was desperate because the last thing that [President Lyndon] Johnson wanted to see happen was that Medicare would begin with 50 % of the nation not covered in the hospitals they were going to. That would have been a disaster.

GM: I understand. Also you told me that you started out by joining a three-day orientation in  Dallas, Texas, starting on May 12, 1966. What important messages and training did you receive in Dallas and was this a worthwhile experience to start the whole trip?

NR: I don't know about the others, but for me the three-day experience in Dallas was  absolutely transformative. And I attribute that entirely to the field director for the Office of Equal Health Opportunity who was running this whole project. His name was Dr. Richard Smith, he was African-American. He was a brilliant negotiator and he was giving us lessons in negotiating with hospital administrators. [As I learned recently,] he himself actually had been asked by LBJ [President Lyndon Johnson] to go down to Marshall, Texas, and integrate a major hospital there because it was the hospital that Lady Bird Johnson had gone to and it was segregated, and it would have been awfully embarrassing if July 1 came  along and Lady Bird's hospital was still segregated. So Richard Smith went down there. At the airport he was met by a large number of pickup trucks with rifles suspended in the cabs, meant to threaten him. He went ahead, and negotiated with the Board of Directors of that hospital, but at the end of a whole day of negotiations apparently they still weren't quite convinced. So he used the ultimate statement. He said, “Well, you're just about to throw 100 million dollars of Medicare funding out the window”, and he walked out and went back to Washington. Well, a few days later he got  a phone call from the president of the board who said, “We've just fired our CEO and we want to go ahead and integrate the hospital as fast as we can.”

Anyhow, Dr. Smith gave us precepts or principles of negotiating which I still remember to this day and I have used many of them in my life: Be respectful to the hospital administrators. Don't hit them over the head right away with the  fact that they better do this or there's not going to be any money, but rather calmly say that the federal government is firm about this July 1 deadline and that there will not be funds unless there is full compliance. Put it that way and then get the conversation around to how they can integrate the hospital in time for July 1. So that becomes the substance of what you talk about, not whether they should integrate.

Another idea he gave us was that if the conversation gets heated and people  get angry, change the subject and just let time go by until everybody's calmed down and then go back to where you were and try again. These insights we definitely used when we met later on with hospital administrators, but they stayed with me for the rest of my life.

GM: Wasn't there something about speaking to members of the Black community to verify  some of the issues so that you know absolutely what you are dealing with?

NR: Yes, I was going to get to that in a later question but that's fine now. Absolutely! It was key. Dr. Smith told us and we realized when we got down there that the Black community was the main driver of this whole Medicare desegregation effort. For years, members of the NAACP  and other Black groups as well as the Medical Committee for Human Rights had been sending reports to Washington. You heard from Stanley Rapaport, for instance, that the segregated care was always separate, but never equal. And these groups were sending hundreds of reports to Washington. It also happened that, in fact, in Mississippi the head of and founder of the Medical Committee, Dr. Robert Smith, unrelated to the other Dr. Smith, was there. He was one of the supplier of contacts that we would go to. Another was Dr. Al Poussaint who was also a major person in the Mississippi area in getting information on the hospitals. This was absolutely vital.

In fact, we preferentially went to the hospitals where the contacts knew there were these infractions and that they were segregated. So we would walk into the hospitals and already have the information on what was really going on. Sometimes it was hidden, for instance, it would be in a basement—the cafeteria for the Black employees as opposed to the others. The obvious things were signs “Colored” and “White” bathrooms but that was an easy one; they simply took down the signs but still kept things  unchanged. They went to all kinds of lengths.

An apocryphal story which was probably true because several people reported it, was that hospitals did what we called the HEW shuffle. HEW is Health, Education and Welfare, the name of the department at that time. Our certification people were shown a room with two Black patients, one White patient, and one Native American patient, as an example of integration. There was only one peculiarity: all of them were comatose. But this was their way of achieving or demonstrating the fact that they were desegregating.

The Black community was absolutely essential for supplying contacts and information. This could not have happened without them. In fact, the whole operation was remarkable because there was real synergy between government people like myself and the Black community, with both of them working together to make this happen. In May in Mississippi, only 4% [of hospitals] were integrated with a few months to go, and yet, just before the deadline, Mississippi, which was the worst state in the Union as far as integration is concerned, had gotten up to 31%, and afterwards did still better. Many of the other Southern states got up into the 90 percent levels. But this could not have happened without the synergy of both sides working together as a team.

GM: Now as I understand that as you finished this three-day conference you were teamed up with a partner and you as a pair were assigned a particular area of the country to cover. And you were assigned Jackson, Mississippi, an area 75 miles north and another 75 miles south, to see the hospitals in these areas. What were the conditions that you observed in the segregated hospitals?

NR: As I said before, especially before they started changing, it was obvious that the segregated facilities were not equal. They were on separate floors and in just the personnel and  equipment  there was a visible disparity. There was an attempt on the parts of some hospitals, though, to come around, and when we talked to the hospital administrators, for instance, their reactions ran the whole gamut. Some would say, “Look, we understand we have to change and we're going to do it and here's our plan and here's what  is going to happen.” Those were the easy ones. At other places, we had hospital administrators take us aside and say things like, “You know we're glad you're here because you're forcing us to do this and we can say publicly that we're being forced to do it and that gets us off the hook, but really we know it's the better way to do it.”  In fact, the duplication of facilities was already costing them wasted money and they realized that. Then finally, there were some who said, “I'll be damned if I’m gonna change and put a White man in a room with a Black man”. And some of them hung on and kept on that way. I understood that later on, after we had left Mississippi, as the financial implications of Medicare kicked in, even many of those hospitals capitulated: they called it the Golden Rule, meaning who has the gold, rules.

GM: That goes through everything we do. Were all the administrators and the boards White  people? No Blacks were represented in that hierarchy?

NR:  I don't remember any. My memory is  a little fuzzy. I won't swear to that, but it was certainly predominantly 100 %.

GM: It was obviously run by Whites; these were all White run communities. That's why there was a continuing problem, I assume. Tell us some more about some of your notable experiences with the Black community. Did you run into any danger or were you under any hazard at any time during this stay in the South?

NR: Yes, I can relate several memorable experiences. First, going back to the interviews with members of the Black community, we had to be very careful to keep those confidential and, if possible, unseen because if the word got out that members of the Black community were giving us this information that we were using, they would be subject to retribution. And that could be anything from losing their job to more serious repercussions. We all knew that, so we had to be very careful.

I remember we drove out to interview a Black farmer who lived in a shack in a lonely set of fields.  And this man, you know, his English was difficult to understand, he had no education and he was living in primitive conditions. Still, he gave us a very full story of what was going on in the hospitals he had attended. I listened to this and I thought, “This man has courage that I just can't believe.” It was for me a lesson, a big lesson, because this man didn't have a Ph.D. or an M.D. or a B.A. or a high school degree; he probably had a couple of years of grade school in inadequate conditions, and yet his courage was remarkable. It made a light bulb go off in my head -- that courage and education don't necessarily go together. In any event, going back from that interview we were followed by the usual pickup truck with guns hanging in the cabin, as you've heard about from others, probably, or will hear about, and they meant to intimidate us.

On another occasion when we got back to the motel where we were staying, the parking lot which surrounded our unit was filled with these pickup trucks with their guns and people in them and we didn't know what was going to happen next. However, we had been given a telephone number of the FBI in Washington, DC, to call if we ever got into trouble and we were told to use a pay phone because otherwise we'd be listened to. We were also told not to go to local police or to the local FBI but be sure to go straight to Washington. Our problem was that our unit in the motel was across a little grass field from the office of the motel where the public phone was located, so going there we would be in full view of all these trucks. I think I remember racing across this field not knowing what was going to happen. We got to the office. We made the call and somewhere in the next hour, miraculously, all those pickup trucks started pulling out of the parking lot and that was it. We never found out who did what or what happened, but that's how things worked down there.

GM: But I gather from your description that the emotional experience at that moment still hangs tight with you.

NR: Yes,  one I won't forget.

Then the third episode--  even more severe, not personally for us getting injured, but for others, was in Canton, Mississippi, on June 23, 1966. I still remember the date. I was invited and so was my cohort, my partner, Chris Hansen, to go and hear some speeches and meet people from the Meredith March, which was a march that had started in Memphis by James Meredith, who was shot after a few days, but not killed. All the civil rights groups got together and formed a continuation of his march onward to Jackson—which was going to be the terminus of the march. On June 23^rd, they were about a day or so away from Jackson in this town, Canton, Mississippi, and we were invited to meet the people and see the marchers. Chris Hansen actually rendered some medical help there as well. That was all very fascinating except that the marchers had originally planned on camping in a field right behind an elementary school. At the last minute the mayor of the town, we were told, withdrew permission for them to camp and said, “No, you can't camp here.” They had a meeting, and all the major civil rights leaders were there, Martin Luther King, Jr. and Stokely Carmichael and all the others. They had this conversation which was an open conversation as they wanted the whole community of people in the march to be part of the decision. They decided they were going to stay, no matter what. They started assembling a tent and at that point a large bunch of state troopers showed up, wearing gas masks and carrying carbines and billy clubs, and they lined up on one end of the field and announced something like, “You have to leave this field in five minutes or we're going to throw you out.”

Every one of the marchers stayed put, at which point the troopers fired tear gas canisters, not in the air, but directly at people and the place was filled with tear gas. The troopers, of course, had gas masks and  started advancing as a phalanx down this field beating people with billy clubs. As they advanced on the men, women, children, and elderly people, all the marchers were on the field and it was horrible. You heard the beating of these clubs on bones and everything. I was standing at the side of this field and there was a man, a young student, who was injured near the edge of the field and I moved towards him to see if I could help. A trooper pointed his carbine at me and said, “One more step and you're a dead man!”  And so I retreated until the troopers had gone.

It was a horrible experience and witnessing the unbelievable brutality—and also once again the bravery and courage of the Black community, and in this case, White marchers as well. That experience was burnt into my brain for the rest of my life, and also my respect for them. Fortunately, not too many people were seriously hurt. One [may have] had a pneumothorax and had to go to a hospital. Others had other kinds of injuries but not anything fatal—we’re just lucky that didn't happen.

A few days later the marchers did get on to Jackson, Mississippi, and they made a triumphant march down a main street in Jackson which I was there to watch, with Martin Luther King, Stokely Carmichael, and other leaders all marching down the street in front of this whole group of people. I had my heart in my mouth because I knew that anybody up in one of the buildings overlooking the street could be armed and could shoot any of these people. It was a definite likelihood or possibility and nonetheless they marched straight down the street. It was just amazing. So those were the kind of experiences that certainly made me admire enormously what the Black community was doing  and made me want to be of any help I could.

GM: This is obviously part of the so-called peaceful march that Martin Luther King was always fomenting and which he pulled off so many times. I'm curious to know whether the residents, the Black residents of the communities, had guns as well and whether they were ready to protect themselves should they be set upon.

NR: Well, I listened to the interview with Stanley Rapoport about the Deacons and Bogalusa [Louisiana] and I never heard of that kind of organization in Mississippi. The people there, I think, were generally committed to non-violent actions, even though Mississippi was, if anything, worse than Alabama in terms of the brutality that they were subject to.  In fact, I don't want to get off the subject, but that march was around the turning point in terms of the Black resistance to White suppression in that “Black power” became the new motto. Stokely Carmichael and others like him took over—this was related to that Canton episode. John Lewis who had been the head of SNCC was demoted as it were because he stuck with MLK Jr. on non-violence. John Lewis after that Canton episode and everything else, left for Atlanta and the rest is history, as you know, about his life. It was a turning point for the whole civil rights movement. I didn't realize what was going on at the time. I heard “Black power” being talked about but didn't realize that many people were shifting in that direction.

GM: Is there any difference that you could notice in your activity at the hospital level before and after this episode?

NR: No, not really, other than the changes in obvious segregation practices, as far as I could see.

GM: These were very interesting details that you can come up with and obviously you remember them in great detail which is understandable. What do you feel you accomplished  with your work in Mississippi in attempting to desegregate the hospitals, as you look back?

NR: Certainly, the whole project, as I mentioned before, in this very limited time and with a massive amount of work to do, was surprisingly successful. Nationally, over 90% of hospitals were ready on July 1, 1966 for Medicare. In hospitals in the South, over 70% were in compliance and were going to receive Medicare. Mississippi was, as expected, in the tail end at about 31% [of available beds].

On the whole, this project was an amazing success in terms of de jure segregation, that is the obvious things about segregation of medical care, whether mixed races are in the same room or cafeteria or bathrooms or laboratory facilities and  so on. All of these things changed, and it had to improve the quality of medical care where that happened. Still, we know that infant mortality, for instance, is still much higher in the Black community in Mississippi than in the White community and [probably] so are all the other health disparities that  you would expect, because there are so many social determinants of health, as you know, that go into that: nutrition, clean water, employment, stress, and so on.  Given those important determinants, desegregating the hospitals does make a difference but in terms of the overall health of the Black community, it is just one step. Decades of work still need to go on.

For instance, I didn't mention that Chris Hansen, who I worked with in Jackson, was moved so much by seeing all of what I've described that he quit the Public Health Service and joined up with a community health center starting in Mount Bayou, Mississippi, which was not far away from Jackson.  He worked there as a pediatrician for several years. And later, community centers like that one proliferated all over the country, as better ways to deliver health care in low-income communities. So [Chris’ work] may be considered an indirect outcome of our experiences in the South.

On the other hand, as Preston Reynolds, a doctor who's a historian of this period, explained to me very recently, what we did was to set a bar, a kind of ethical bar, so that at least the medical facilities will not be radically different between Black and White, there will be equal access of Black and White doctors to hospitals and so on. So we've set a bar but we have a very long way to go—as we saw during the coronavirus epidemic, the fact that Blacks were dying of the virus twice as often as Whites reflects their pre-existing underlying health conditions. So we still have a long ways to go.

GM: Yes, I have to agree with you on all that without any question. How long were you in the South?

NR: Two to three months. I can't remember exactly but I seem to remember that I went back after July 1  for another period of time, which might have been another week or two, to kind of mop up some more hospitals. The total would have been two to three months.

GM: How many hospitals do you remember visiting? Would you guess?

NR: I can't give you an accurate number. I wish I could. We were there for let's say 70 or 80 days working and some of those days were used to interview patients, so maybe 40 to 50 hospitals, I'm guessing, just estimating from the time we were there. We had to drive to these hospitals if they weren't right in the center of Jackson, so that took time also.

GM: That was quite an undertaking when you put it in those terms. You went back to NIH after this episode. How long did you stay there? What did you do while you were there?

NR:  I went back and continued with my research at NIH. I left in 1968, and after a year of doing  research in Japan, I returned to become an assistant professor at Case Western  Reserve School of Medicine where I stayed for the rest of my career. I rose to a full professor and continued my research and teaching. My research was on the neuromuscular junction because it represented a model synapse and you could study plasticity. I was interested in change of synaptic function with use, disuse, aging, and so on. Those were the areas that I worked on for my whole career.

GM: I assume that research is still going on since you retired?

NR: Do you mean other people continuing that research? There still is. The reason is because it's a very accessible system, as opposed to the central nervous system where you might in one little millimeter of brain, have 10,000 neurons to worry about. At the neuromuscular junction, you have just this one neuron that forms a synapse with the muscle and so it simplifies analyzing changes in synaptic physiology and morphology.

GM: Was your research on animals or humans or both?

NR: Both. Mostly animals, but it's actually fascinating that the changes in ultrastructure of the neuromuscular synapse in old humans, people like myself, were the same as changes in 24-year-old mice who at most lived to maybe 36 months in the laboratory, so there was a similarity of aging as a proportion of the lifetime and the structural changes that we observed. We felt we had a good model of human aging and we used that to study, for instance, the physiology of aging at neuromuscular junctions.

GM: Looking back, how would you say your experience and your trip to the South influenced  your subsequent thinking as far as community involvement as the years went on?

NR: There was no question that this experience was transformative for me. I saw this wonderful  model of effective activism that involved persistent pressure from the Black community that eventually brought along the government -- and, as I mentioned before, the combination of the two working together was powerful. Accomplishing what they did in three or four months, bringing thousands of hospitals into compliance for desegregation -- it's just unbelievable.

That was kind of a high-water mark, but on the other hand, we saw the need in the Black community for a better life in general and the oppression that was so obvious in the South. It also was there in the North although not so obvious. I just felt that at some time in my life I would have to do something about this. I also enjoyed the esprit de corps of all of us – Black and White -- working together on something very meaningful.  So I think the idea that a diverse community could create change was part of that realization. All of this was totally new to me and I had several years to filter and percolate. Several years after I got back to Cleveland and Case Western Reserve, I found that besides my research, teaching and family life,  I needed to do something in the public domain. And over the ensuing years, I worked in three areas: environment, peace, and social justice. I'll just give a few examples.

In environment, I founded and led a citizen recycling group that worked with our local city to start the first self-supporting recycling program in northern Ohio. Much later, I directed a seven-county public-private project to look at regional environmental priorities. What were the most important environmental issues that needed to be addressed in our region? One of the [indirect] outcomes of that was formation of a committee on indoor triggers of environmental factors that included, especially in urban areas, lead poisoning and triggers of asthma. Those were major health problems of Black populations, especially in urban areas such as Cleveland.

In the area of peace, I founded and started in the middle of the Cold War a sister-city organization between my town [and a neighboring town] and a town in the Soviet Union. We traveled over there several times and had many citizen exchanges as a way, we hoped, to defuse animosity. What we found was that the people in the Soviet Union were absolutely thrilled to have us visit and to be able to come over here, because they shared our fear of a nuclear outcome of the Cold War. That was a unique experience again where negotiating skills came in handy, especially working with Soviet officials.

Then after I retired in 2002, I spent about 15 years volunteering with non-profits on voting issues. I did research on voting issues that was applied to advocating for equity and voting rights, mostly those affecting the Black community. Together, we figured out ways to demonstrate that there were voting restrictions that were unequal and needed to be addressed. We also figured out ways to improve administrative procedures so people could vote more easily, and in the later years, we identified ways to increase turnout in the Black population. So I did get back to the social justice issues that started percolating in Mississippi.  I guess I could say that the seeds for all this volunteer activism in my life may have been planted by my mother early on, but they were watered by my experience in Mississippi in 1966.

GM: You have certainly excited me with all of this and I'm sure you will have excited many more  people who see this program as time goes on as we put this up on the website at the Office of NIH History as part of a permanent record of what's happened with our faculty in the South. You've given such an interesting and detailed and coherent report of your experiences that will prove to be a very important historical document that people will be looking at for many years. Your contributions, personal and otherwise, have been extensive. You’ve been most helpful all the way through. I thank you so much. I'm grateful to  you. I do hope we'll have a chance to meet in person once this epidemic disappears.

NR: That would be wonderful. Thank you so much for doing this. I think this whole effort, beginning with the work of people like Stanley Rapoport before the Medicare effort, and how it all came together, is a great story. There’s a video called “The Power to Heal” that's available from, I think the company’s called Bullfrog, and it has a famous American historian who says that the two presidents who did the most for civil rights were Abraham Lincoln and Lyndon Johnson. Johnson did see where all this was going but it started with the Black community. They drove this effort but Johnson had the wisdom to go with it and carry it as far as he could get during his time in office. I think it's a great example of something very positive in American history.

GM: Especially since Johnson was a man from the South and lived through all this personally.

NR:  It  was just amazing. Thank you.