Summers, Martin. Madness in the City of Magnificent Intentions: A History of Race and Mental Illness in the Nation’s Capital. New York: Oxford University Press, 2019. Xiii+390 [ISBN 978-‍0-19-085264-1 tapa dura].

While researching my book on psychiatry in Buenos Aires in the 1990s, I commented to an archivist about the deplorable conditions in Argentina’s psychiatric hospitals. She quickly responded, “And the homeless in Washington, D.C., your hometown?” Indeed, ever since President Ronald Reagan twisted deinstitutionalization into a neoliberal nightmare, the city is notorious for its mad homeless. Many are black, and in the 1980s, when I was in high school, many had been just released from St. Elizabeths hospital.^‍‍[1]

That hospital, its doctors, nurses, staff, patients, their families, and the African American community in Washington, D.C. are the subject of Dr. Martin Summers’ Madness in the City of Magnificent Intentions. St. Elizabeths was one of only two federally operated psychiatric hospitals. The other one was the Canton Asylum for Insane Indians in South Dakota. ( ‍Joinson, Carla (2016), Vanished in Hiawatha: The Story of the Canton Asylum for Insane Indians, Lincoln, University of Nebraska PressJoinson, 2016) At its founding in 1855, its target population were members of the military but also residents of the District of Columbia, which was the only federal territory that was also a city. Overtime, the percentage of the patients who were African American increased.

Visitors to Washington, D.C. today would be surprised to know that the city was a southern city. Until the Civil War, it was a city where enslaved blacks lived side by side with a sizable population of free people of color and whites of all classes. After the 1870s, blacks lived under the strictures and humiliation of Jim Crow rules of segregation and subordination. St. Elizabeths therefore is an apt hospital to study the complex and cruel intersections between psychiatry, racism, race consciousness, and American history.

Anti-black racism has shaped evolving ideas about the so-called “black psyche.” Before emancipation, African Americans were considered to be largely immune to mental disturbances, especially melancholia. Slaves who ended up in mental hospitals were often suspected of feigning madness to escape bondage. During the Civil War and after emancipation, mental medicine updated its view of blacks and noted that freedom had unleashed African Americans’ ‘atavistic nature.’ As Summer notes, “insanity was racialized in a way that reproduced prevailing cultural notions of blacks as ignorant, primitive, criminally prone people who were incapable of adjusting to, much less thriving, in modern America.” (73) Over the following century, the psychiatric view of blacks would change, but seemed to forever return to this original view of the inherent psychopathology of African Americans. The constant was that psychiatrists always were careful to put a medical veneer over their prejudice. Whether the theoretical framework was dynamic psychiatry, somatic or neuro-biological frameworks, psychoanalysis, or social psychiatry, somehow the clinical assessment usually boiled down to race. Even after World War Two, when American psychiatry took note of the United Nations and banished explicit racism from its study of blacks coded language emerged to cast blacks as both excessively deranged and paradoxically ill suited for the more advanced medical interventions.

Race also shaped treatment pathways and housing decisions. Blacks were considered ill suited for psychoanalysis because of their supposed childlike nature. By contrast, harsh somatic treatments like hydrotherapy were over prescribed for blacks because they were viewed as especially prone to mania, violence, and hypersexuality. Summers’ careful study of case files for patients also indicates that white doctors likely often misunderstood statements by black patients. In some cases, for example, they would read into what Summers calls “black vernacular paradigms of disease” to see signs of mental illness. (113)

St. Elizabeths Hospital, like all hospitals in the South (and many in the north) kept blacks and whites in separate wards. Segregation by race produced other noxious consequences. Hospitals had to somehow manage three different categories of separation: gender, race, and diagnosis. Budget strapped hospitals like St. Elizabeths, which had always prioritized the well-being of white patients over that of blacks, would often house black men of all diagnostic categories with the “criminally insane.” (107) Such custodial decisions were of course in some quiet way justified by the belief that almost always “black insanity approximated the most pathological and violent form of insanity among whites.” (123) Strikingly, just as doctors disguised their racism behind medical lingo, custodial segregation was framed as being in the best interest of both whites and blacks. In the end, black needs were always subordinated to those of whites. (124)

African Americans’ relationship to the hospital was, however, more complicated than one might expect. On one hand, African Americans had a healthy dose of skepticism about a carceral institution, and especially one dominated by white staff and doctors. Moreover, as Martin Summer notes elsewhere, the African American medical community had at times been reticent to talk publicly about mental illness among blacks for fear of reinforcing the very prejudice to which they had been subjected. Physical ailments, by contrast, were more visible signs of the ill-effects of Jim Crow discrimination and had more rhetorical power ( ‍Summers, Martin (2014), “Diagnosing the Ailments of Black Citizenship: African American Physicians and the Politics of Mental Illness, 1895-1940.” In B. Green, Lauri; McKiernan-Gonzalez, John; Summers, Martin. (eds), Precarious Prescriptions: Contested Histories of Race and Health in North America, Minneapolis, University of Minnesota Press, pp. 91-114.Summers, 2014). Nevertheless, African Americans also saw the federal hospital, situated in their own city, as a resource to which they could claim rights. Families and neighbors sent loved ones to St. Elizabeths, petitioned for the continued or improved care, petitioned for their release when they felt that was appropriate, and agitated against segregation. On the question of segregation, African Americans knew that the doctrine of “separate but equal” was a complete lie. It was a matter of life and death. Patients also advocated for themselves. In the post Civil War, an African American doctor who was a patient at the hospital complained about finding himself, surprisingly, sharing a room with a Confederate colonel who screamed racial slurs all day long. (103) Segregation also had a deleterious effect on medical training. Students at Howard University, Washington’s ‘historic black university’ founded after the Civil War, could only examine and work with their fellow African Americans. White patients could refuse to be seen by black health professionals. Even federal efforts to desegregate, starting during the New Deal in the 1930s often could not crack white patients’ refusal. (238)

Deinstitutionalization began both because of humanitarian concerns about hospital overcrowding and abuse of patients and lawsuits by patients claiming that they had the right to the “least restrictive” treatment that was medically appropriate and effective. (298) The process was helped along by the advent of a variety of pharmaceutical interventions. Sadly, the process was hijacked by the neoliberal imperative which in the US called for public health devolving to the individual states and the District of Columbia. These processes unfolded in the wake of desegregation and other positive developments in the delivery of mental health services, including the expansion of extramural services to citizens of the city.

In this reviewer’s opinion, Summers’ book is the most comprehensive study of African Americans and psychiatry that has been published to date. It does suggest some areas of future research. First, as a federal institution, it also housed some Native Americans, residents of other US territories, and military personnel. After the Mariel Boatlift, the hospital also held a sizable number of Cuban refugees. As Jennifer Lambe notes, they arrived to the hospital just as deinstitutionalization was moving forward ( ‍Lambe, Jennifer (2017), Madhouse: Psychiatry and Politics in Cuban History, Chapel Hill, University of North Carolina Press.Lambe, 2017). Those stories, at some point, might be folded into our understanding of how race operated beyond the white-black binary. Second, scholars of psychiatry in Latin America will want to get a better understanding of how the American racial obsessions and their medicalization compare with other areas. Many studies have indicated that Latin American psychiatrists, generally, were far less obsessed with racial difference than their US counterpart ( ‍Rios-Molina, Andres (2019), “Racial Degeneration, Mental Hygiene, and the Beginning of Peruvian Psychiatry, 1922–1934,”History of Psychology 22:(3), pp. 225-243. Rios Molina, 2019).

Martin Summers book is ambitious in scope and scale and he expertly connects the story of American psychiatry to not just St. Elizabeths but also Washington, D.C. Readers should pay special attention to the myriad ways the medical ideas were repeatedly hijacked by racial prejudice. He also shows the paths of black survival that emerged. Noteworthy is the generation of black psychiatrists who began to explore the impact of racism on black well being after the Second World War. (255). Summers keen observations about the impact of medical inequality in the United States comes at a time when we see the devastating impact of COVID-19 on communities of color.