- Malicious Intent
Murder and the Perpetuation of Jim Crow Health Care
Race-related disparities in American death rates, exacerbated once again by the COVID-19 pandemic, have persisted since the birth of the modern US medical system a century ago. A unique but perpetually unequal history has prevented the United States from providing the kind of health care assurances that are taken for granted in other industrialized nations. The underlying story is one of political, medical, and bureaucratic machinations, all motivated by a deliberate Jim Crow systemic design. In Malicious Intent, David Barton Smith traces the Jean Cowsert story and the cold case of her death as a through line to explain the construction and fulfillment of an unequal health care system that would rather sacrifice many than provide for Black Americans.
Cowsert’s suspicious death came at a key moment in the struggle for universal health care in the wealthiest country on earth. Malicious Intent is a history of those failed efforts and a story of selective amnesia about one doctor’s death and the movement she fought for.
Part I. Race and Recovery of Memory
1. A Forgotten Death
2. Jim Crow Medicine
3. Death of Universal Health Care
Part II. Mobile
4. Old Wounds
5. Civil Rights Struggles
6. Local Medicine
Part III. Jean Cowsert, M.D.
8. An Irresistible Force Meets an Immovable Object
9. Eliminating the Jim Crow Cages
David Barton Smith is a professor emeritus in health administration at Temple University and research professor in healthcare management and policy at Drexel University’s Dornsife School of Public Health. He is the author of The Power to Heal and Reinventing Care (also published by Vanderbilt) and Health Care Divided: Race and Healing a Nation.
"Malicious Intent investigates two mysteries: what caused the 1967 death of Jean Cowsert, a courageous physician in Mobile, and why extreme health disparities persist in the United States. David Barton Smith finds the solution of both in the history of racism in America, of which he is a foremost chronicler."
—Timothy Stoltzfus Jost, author of Health Affairs' Following the Affordable Care Act blog (2010-2017)
"David Barton Smith sees health care reform as having been stifled by racism, and in that sense Dr. Cowsert's death serves as a metaphor—a way to humanize and personalize the struggles and costs of health reform."
—Keith Wailoo, author of How Cancer Crossed the Color Line
“Dr. Smith’s work represents a significant contribution to the literature on structural racism and the history of healthcare, providing important context to much-needed contemporary discussions of the subject.”
—Stuart Wexler, author of America's Secret Jihad: The Hidden History of Religious Terrorism in the United States
Beneath the surface, that death, was but one of many lost to memory in a struggle begun by 19th century abolitionist. All these murders became unsolved cold cases.
Healthcare in the United States is the “ultimate cold case.” It captures all that is unique about this nation - one whose utopian vision of democracy has kindled flames all over the world but has avoided confronting its own racial realities.
Most answers to these two questions blame “structural racism” but get vague in describing what it is. While the watershed Civil Rights Act of 1964 prohibited “racial discrimination,” it never defined what that was. Current advocates of “antiracism” avoid confronting the “structural” part. They argue that it is just an easy excuse to do nothing. Most focus on “organizational culture” and all the conscious and unconscious biases that shape hiring, promotion and treatment decisions.