Читать книгу More Than Medicine - Jennifer Nelson - Страница 9

The women’s health movement of the 1970s emerged from an earlier movement focused on the use of health care to end poverty in the United States. Health care reform activists of the 1960s, some of whom joined the feminist health reform movement in the 1970s, forged what they believed would be a comprehensive and community-based solution to poverty eradication. Although the implementation of their solutions was never quite as sweeping as some activists wanted, they successfully garnered substantial federal dollars for their programs. These activists intended to use Neighborhood Health Centers (NHCs) to eradicate poverty and to restructure the social hierarchies that ensured certain groups’ “generational poverty” by providing health care, linked social services, and economic supports necessary to ensure individual and community health. As Dr. Harry P. Elam, codirector of Mile Square Health Center in Chicago, asserted, “In the ghetto, you cannot separate the delivery of family medical care from housing problems, underemployment, culture, traditions, and mores. Although this concept is not part of traditional medicine, it is the new focus needed in working with the poor today.”1

One of the key concepts behind the NHCs was that real health could only be achieved if medical care addressed the socioeconomic roots of ill health. This idea influenced medical delivery and training in subsequent decades. H. Jack Geiger, one of the founders of the movement, noted the extent to which changed definitions of health and health care influenced young medical students and doctors by 1972, less than a decade after the creation of the first NHCs: “Substantial numbers of physicians were trying to learn something about the economics of medical care . . . and trying to bring new kinds of medical care services into being instead of perpetuating the old.” He argued that these young physicians understood that there was “something wrong with the social order . . . to the extent it makes large numbers of people sick by condemning them to miserable housing, hunger, joblessness, social and biological and environmental stress.”2 Feminist activists of the 1970s employed a similar concept of comprehensive health care that addressed medical care as well as its social context; they developed a broad critique of gender oppression and sex inequality promoted by medical institutions.

This chapter tells the story of the evolution of the NHCs and these new understandings of health care and what it meant to be healthy. NHCs were founded during a grassroots initiative that partly grew out of the civil rights and New Left movement calls for greater “participatory democracy” among those without access to social power or economic resources. NHCs flourished in the 1960s with support from the Johnson administration’s War on Poverty spending linked to the Office of Economic Opportunity (OEO). The successes of the NHCs helped perpetuate the notion that real health required broad socioeconomic solutions that targeted and empowered residents of local neighborhoods and communities. NHC planners chose to locate health centers within neighborhoods because residents of neighborhoods faced similar health and socioeconomic problems. Residents also often shared extended family, ethnic or racial ties, and other social connections that could facilitate finding solutions to these problems. Neighborhood affiliation, perhaps most importantly, also encouraged consumers of health care to feel that the health center belonged to them, particularly if they worked there or sat on a community board for the center. Rather than foster feelings of inferiority or exclusion—as many hospitals had done in the past—NHC organizers wanted to empower community residents to make decisions about their own medical care, theorizing that involvement would encourage people to access health resources more readily.

Ideas about community empowerment in the 1960s originated with the civil rights movement, particularly in organizations such as the Student Non-Violent Coordinating Committee (SNCC), which was led by the seasoned civil rights activist Ella Baker. Baker believed that people should become empowered by being their own leaders.3 The notion of empowerment also resonated strongly with New Left activists—many of whom had also been involved with SNCC—in organizations such as Students for a Democratic Society (SDS). SDS participants and other New Left activists promoted the idea that people did not need powerful leaders; instead, communities would lead themselves.4 This perspective, coupled with growing popular-media attention to pockets of persistent poverty in the United States (despite national economic growth), led activists to believe that solutions to poverty depended upon the participation of the powerless in finding structural solutions to persistent and complex community deprivations.5

Community leadership and empowerment as central ingredients in the fight to alleviate poverty also had roots in academia. Lloyd Ohlin and Richard Cloward, academics associated with Columbia University and the University of Chicago and funded by an organization called the Gray Areas Project, a cover for the Ford Foundation, applied notions of community empowerment in the new urban northern “ghettos.” In 1962, the Gray Areas Project funded Mobilization for Youth on the Lower East Side of New York. In Mobilization for Youth they implemented the concept that community involvement in the process of ending poverty would empower the poor to gain control over their own lives.6 Ohlin and another sociologist, Richard Boone, developed the idea of community empowerment further in President Kennedy’s Committee on Juvenile Delinquency. The idea was eventually repackaged as “community action” as it became central to President Kennedy’s staff on the Council of Economic Advisers, a group influenced by the “Keynesian Revolution” and appointed to grapple with the poverty issue. Community action was meant to offer coordinated social services (in one location) within poor neighborhoods to make those services more accessible to people who needed them and also to connect the services and the service providers to the communities. Community action also required that social services be responsive to the needs of the poor as articulated by the poor themselves, not by bureaucrats or social workers living outside of poor communities.7 As Alice O’Connor writes in her comprehensive treatment of the history of government involvement in antipoverty policy, community action promoted “the notion that the federal government would act as a catalyst for change and local community ‘empowerment.’”8

Antipoverty programs initiated by the Kennedy administration gained renewed traction under President Johnson with his War on Poverty, although he had reservations about community action. Others in his administration, particularly Richard Boone, along with Sanford Kravitz, Frederick O’R. Hayes, and Jack Conway of the United Auto Workers,9 were strong advocates of the idea that the poor needed to be empowered politically as community leaders to end poverty. More practically, “maximum feasible participation” among communities targeted for antipoverty federal dollars could also help ensure that southern organizations would not set up all-white antipoverty programs. Sargent Shriver, appointed by Johnson to head the new antipoverty program, institutionalized in 1964 by the Economic Opportunity Act as the Office of Economic Opportunity (OEO), adopted ideas associated with community action but made the idea more palatable to conservatives by marketing it as a way to end a “culture of poverty” and give the poor a “hand up, not a hand out.” Tension between the politically radical notion of ending poverty through the empowerment of the urban and mostly black poor and ending a culture of poverty by training the poor in middle-class values continued to haunt antipoverty programs funded by the OEO.10

Despite this tension, ideas about empowerment that informed the nationwide system of National Health Centers were often idealistic and grounded in a faith in revolutionary change that found expression in the civil rights movement, New Left organizations like SDS, as well as the anti–Vietnam War and student movements, and the progressive wing of the antipoverty movement linked to the War on Poverty that first coined the phrase “maximum feasible participation.”11 Many of those involved in creating and running the NHCs believed that a comprehensive system of community-based health care delivery had the potential to help end poverty and racial inequality in the nation. Although their achievements fell short of these goals, their efforts are worth recounting and considering as we continue to debate how best to reform health care in the twenty-first century in a society still deeply divided by income, race, ethnicity, and sex.

While NHCs existed across the nation, this chapter focuses on the Tufts-Delta Health Center in Mound Bayou, Mississippi, the first rural comprehensive NHC funded by the Office of Economic Opportunity (OEO).12 I spotlight the health center in the Delta for several reasons. First, there is a large body of primary evidence on this particular center that has not been closely examined by historians focused on the War on Poverty or health care reform. The Tufts-Delta Health Center in Mound Bayou illustrates how the NHC model worked to “overcome the serious obstacles that have made it difficult for poor people to obtain high quality, personal health care,” an explicit goal of those who designed and implemented the program.13 Second, the Tufts-Delta Health Center stands as an important instance of a successful experiment in health care reform. While all NHCs were not as successful, the model for a transformed system of health and health care delivery worked well in Mound Bayou. Third, the Tufts-Delta Health Center provides an excellent example of grassroots support for health care reform. These grassroots efforts were essential to the health center movement’s successes and a core element of the NHC reformers’ vision for a new health delivery system. Finally, the Tufts-Delta Health Center sources shed light on how women in the community were fundamental to the health center as both health care providers and patients. Women and children as patients and women as practitioners were significantly impacted by the success of the health center in Mound Bayou.

The Tufts-Delta Health Center had counterparts across the country and supporters of community medicine worked towards health care reform in a variety of forums not necessarily associated with federally funded NHCs. To demonstrate the broad reach of these ideas, I also devote part of this chapter to an examination of a series of early 1970s reform efforts in New York City that were less successful than the federally funded NHCs but illustrate the widespread existence of these ideas. The next chapter on the women’s health movement is also illustrative of the broad impact of ideas about social medicine and the potential for transformed health care delivery systems to affect changes in relations of power.

The civil rights movement of the 1950s also addressed health care, but focused primarily on hospital desegregation, including guaranteeing access to hospitals for black patients and equal medical education for black physicians. Hospitals finally began to desegregate in the southern states after the Fourth Circuit Court of Appeals ruled in 1964 in Simkins v. Cone that hospitals that had received federal funds authorized by the Hill-Burton Hospital Construction Act needed to desegregate or return their funds. The Supreme Court affirmed the lower court ruling, which invalidated a “separate-but-equal” provision in the original Hill-Burton Act from 1946 that permitted segregated medical facilities. Hill-Burton had provided substantial funds for hospital construction nationwide after World War II but also ensured that hospitals in the South would continue to exclude African Americans or segregate them in inferior wards.14 The Simkins v. Cone ruling came on the eve of congressional passage of the Civil Rights Act of 1964, which included the Title VI provision authorizing the Department of Health, Education, and Welfare to withhold public funds from institutions that discriminated on the basis of race.15 The Simkins ruling, the Civil Rights Act of 1964, and the creation of Medicare in 1965 gave the federal government the legal and financial muscle it needed to begin to push for desegregation of medical institutions in the South.16 Segregated medical care had long contributed to poor health among African Americans in the South. Desegregation was an important first step towards improving health among blacks in these regions. At the same time, hospitals found ways around desegregation by converting to private rooms and refusing hospital privileges to black doctors.17

While Congress worked to strengthen the Civil Rights Act to provide the federal government with a mandate to enforce new laws against segregation, grassroots movement activists worked simultaneously to transform a culturally segregated southern society. Jim Crow culture was slow to change even after federal law swept away de jure segregation. Many whites and even blacks in the South were so accustomed to a segregated society that they were loath to break customary barriers between the races that reinforced inequality often as powerfully as did legal barriers.

The Freedom Project, organized for summer 1964 by civil rights groups in Mississippi such as the Student Non-Violent Coordinating Committee (SNCC), was as much an attack on southern Jim Crow culture as it was a drive for voter registration. The project brought hundreds of college students to Mississippi to help register black voters and to lend their support in the often overwhelming and exhausting effort of sustaining southern blacks to keep up the fight against embedded traditions of segregation and racial inequality.18 Over the course of the summer, white northern college students spread out across Mississippi to teach in freedom schools, register black voters, and lend a hand in local voter registration and community projects sponsored by SNCC and the Congress for Racial Equality (CORE).19

Accompanying the college students were groups of professionals, including lawyers, law students, ministers, and physicians who also traveled south but often for shorter terms—sometimes just for a week or two—to lend their professional skills and services to the movement. One group of New York physicians traveled to Mississippi for the 1964 Freedom Project with the Medical Committee for Human Rights (MCHR) to provide first aid and basic medical care for civil rights workers. Some of these physicians also felt it was imperative to help end discriminatory health practices in Mississippi. This perspective formed the basis for extending their medical contributions beyond a single freedom summer.20

The mid-1960s was a pivotal time in the civil rights movement as organizations sought strategies to energize activists increasingly skeptical about the movement’s continued progress. The 1964 Summer Project was a formidable effort that succeeded in channeling new energy into the movement and also drew national attention to continued southern resistance to civil equality. Organizers gambled correctly that by bringing elite and white northern college students to Mississippi, they would attract new national attention to the fight for racial justice. The deaths of two white middle-class volunteers, Andrew Goodman and Michael Schwerner, and one black Mississippi civil rights worker, James Chaney, brought home the high cost of that gamble; but the deaths of the volunteers also focused the attention of the nation on Mississippi and the movement for racial equality. Beyond the deaths of these three young men, 1964 was a summer of severe violence, including lynchings, beatings, bombings, and the burning of buildings. Yet, activists also began to see a transformation in the political orientation of the movement. With the passage of the Civil Rights Act of 1964 and the Voting Rights Act of 1965, many people around the nation believed the movement had achieved its goals. Of course, blacks in Mississippi knew that racial justice was still not a reality as white Mississippians mounted fierce resistance to the new federal laws. Organizations like SNCC became increasingly frustrated with the promise of integration and nonviolence and, as a result, began to focus on Black Power and Black Nationalism.21 The turn to Black Power also renewed interest in building black community control over local institutions. Demands for community control originating from civil rights and Black Power activists would be influential on NHC programs funded by the federal government.

According to historian John Dittmer, individuals with two different sets of goals contributed to MCHR work in Mississippi during the summer of 1964. Their health care work and objectives were compatible but not identical. One group focused on the narrower goal of providing medical and immediate emergency care to the civil rights workers. The other group came to Mississippi with the broader and long-term goal of eradicating and replacing the southern segregated and discriminatory health care system with an egalitarian one. The second group, led by physician activist H. Jack Geiger, who, at the time, was the Mississippi field coordinator for MCHR, extended their stay in Mississippi and in other southern states after other northern civil rights activists returned home. By the fall of 1964, MCHR activists in Mississippi had established projects to provide health care to poor African Americans and had made plans to extend the program nationally. This group of MCHR activists played a pivotal role in the transformation of health care access for the poor in the South and elsewhere in the country in the 1960s.22

As the goals of the civil rights movement shifted away from gaining the vote and ending legal segregation in the South, MCHR physicians like Geiger channeled War on Poverty funds into medical clinics in both the North and the South to help empower poor African Americans—and poor Americans in general—to become involved in their own health care improvement and delivery.23 Experience in the civil rights movement convinced Geiger that any real changes to health care delivery needed to fundamentally involve those who would benefit from the services. Thus, a few members of MCHR, founded to provide limited emergency aid to civil rights workers, expanded their goals when President Johnson’s War on Poverty offered financial support for the transformation of health care delivery to the poor.

The most successful Neighborhood Health Centers brought local residents and patients into the planning and implementation of the institutions from the very beginning. NHCs also employed residents, who often lacked a college education or even basic skills, to take paid positions as day care workers, in after-school programs, as employment counselors, in outreach programs, or as health aides. Thus, residential staff could gain skills and professional experience and even advanced degrees through the NHCs (some of whom partnered with local community colleges) that would help them to direct or manage programs within the NHCs or use their skills to find professional employment elsewhere. The goals of the NHCs surpassed the simple distribution of medical care in commodity form—to be exchanged within a marketplace that at best lowered the cost for the poor. Instead, the NHCs were designed to empower the least powerful members of society and to radically transform a deeply anti-egalitarian culture that had embedded inequalities within institutions such as clinics and hospitals.24

Although there is not one individual responsible for the creation of Neighborhood Health Centers, Dr. H. Jack Geiger was pivotal to the creation of a nationwide system of NHCs. He promoted a vision of medicine as not only a tool for individual health care but also a tool for community transformation.25 He also believed that health care could be used to promote empowerment if members of the community were given an “assured role in the design and control of their own health services.”26

Geiger imported the seeds for the community medical center that was built in Mound Bayou, Mississippi, from Pholela, South Africa, where he had traveled in the 1950s while in medical school on a Rockefeller Foundation grant to investigate a health center also funded by the Rockefeller Foundation.27 Physicians Sydney and Emily Kark had created the Pholela Health Center in 1940 to serve a Zulu “tribal reserve” that suffered from desperate poverty. The emphasis at the clinic was not merely on individual health but on promotion of health for the entire community. Kark and other health care providers at the Pholela Health Center were principally attentive to environmental factors, including sanitation, as major contributors to the community’s ill health. They also focused on nutrition and basic preventive care. Everyone in the community was considered a patient regardless of his or her ability to pay for health services elsewhere. This model was so effective that Kark exported it to other South African health centers, including one at Lamontville, a housing project outside of the city of Durban. Kark and his colleagues targeted communities with “high birth rates, high death rates, a heavy burden of both infections and chronic disease, low levels of employment, low literacy, substandard housing and nutrition, and limited medical care resources.”28

In June 1964, as a participant in the Mississippi Freedom Project, Geiger connected his experiences with the health centers in South Africa to the desperate poverty he found in the southern United States. Geiger traveled to Mississippi in 1964 as a member of MCHR, taking time off from his new position on the faculty of the Harvard School of Public Health. During his month-long stint as a doctor-activist in Mississippi, Geiger found that African Americans lived in communities that were as poor and unhealthful as those he had seen in the tribal reserves of South Africa. He wrote that he “took a long, close look at the poverty, misery, and deprivation—and, inevitably, illness—in the sharecropper shacks and small-town black slums of the Deep South.” He recognized that he didn’t have to go to Africa to find poverty, as “there was a third world in the United States.”29 Geiger and several other physicians from MCHR, together with the Delta Ministry, a Mississippi civil rights organization, committed to staying in Mississippi once the Freedom Project had ended to continue providing health services for poor African Americans.30 Several nurses also came south for the Freedom Project and remained in Mississippi to provide health care services with MCHR and the Delta Ministry. One of these, Phyllis Cunningham, discovered that local people were often more comfortable interacting with a nurse than with a doctor. Cunningham provided pregnancy-prevention classes, helped organize for better sanitation facilities and regular garbage pick-up, and helped provide vaccinations.31

At a November 1964 meeting, after several months of experience in ad hoc health care provision among the poor black residents of the state, Jack Geiger, Count Gibson, and other MCHR and Delta Ministry physicians brainstormed about the best way to institutionalize better health services for poor African Americans in Mississippi.32 Geiger argued that a community health center modeled on the one he visited in South Africa in Pholela was the best way to make a long-term commitment to solving comprehensive health problems associated with poverty among African American Delta residents.33 He also argued that the health center should be controlled by the local blacks who would use it. Gibson, fellow activist and chair of Preventive Medicine at Tufts University Medical School, and John Hatch, professor and civil rights volunteer in Mississippi, decided to partner with Geiger. Gibson offered Tufts Medical School as a sponsor for the project and proffered Geiger a full professorship at Tufts so he could oversee the health center project. Hatch was the only African American of the three. He was born in Kentucky and, as he explained in an interview, had grown up in Arkansas on “the banks of the Mississippi River” and often earned money “working in the fields picking cotton.”34 Hatch trained as a social worker at Atlanta University and joined the faculty as an assistant professor of preventive medicine at Tufts Medical School.35

Geiger, Gibson, and Hatch approached the Office of Economic Opportunity (OEO) at the end of 1964 with their idea to implement one Neighborhood Health Center each in an urban and in a rural location, both of which would be administered by the Tufts Medical School. The first grant from OEO—funded with Community Action Program (CAP) dollars—paid for the two comprehensive centers. The Tufts professors, the Delta Ministry, and the handful of doctors and nurses from MCHR still in Mississippi after the Freedom Project ended benefited from growing support for health care reform within Johnson’s War on Poverty agencies.36

Important contextual factors made the mid-1960s a good time to promote radical health reform. For example, Johnson’s landslide victory in 1964 provided the final momentum needed to amend the Social Security Act to support health insurance for those over the age of sixty-five in the form of Medicare and health benefits for families on public assistance with Medicaid. The Watts riots, which occurred in August of 1965, also bolstered arguments that community failure along with poverty contributed to urban violence and ill health in large cities. Many pundits and policy makers began to call for community solutions to poverty and the social ills that accompanied it.37

Due to these gathering pressures to improve health care for the poor, the OEO developed the NHC program presented to them by Geiger and the others at Tufts. The details of the program emerged from negotiations for funding. The first two health centers were planned for Columbia Point, a housing project in Boston, which provided living space for six thousand people in twenty-six high-rise buildings, and in Mound Bayou, Mississippi, a small African American town in Bolivar County, which covered a 500-square-mile rural area. Applications to the OEO for health centers in the South Bronx, Los Angeles, Chicago, and Denver quickly followed on the heels of the Tufts projects. OEO funded all of these health centers as demonstration projects in 1965.38

Quickly, the NHC program funded comprehensive health service grants across the country with significant congressional support fostered by Senator Edward Kennedy of Massachusetts, who had been impressed by the demonstration project at Columbia Point. Amendments to Economic Opportunity Act legislation authorized in 1966 and 1967 established the OEO Comprehensive Health Services Program to fund a national network of more than 150 health centers. Between 1965 and 1971, OEO spent $308 million and the Department of Health, Education, and Welfare (HEW) spent $110 million on the health center program, which served nearly one million people.39 The Economic Opportunity Act legislation from 1966 stipulated that the program should make health services “readily accessible to low-income residents . . . furnished in a manner most responsive to their needs and with their participation and wherever possible . . . combined with, or included within, arrangements for providing employment, education, social, or other assistance needed by the families and individuals served.” By 1971, three-quarters of the centers were in urban areas, filling a gaping hole in urban health care as medical practitioners followed the wealth to the suburbs. Rural centers included a project on an Indian reservation in Minnesota and others near migratory labor camps in California.40

The health centers served the poor for free and the “near poor” on a sliding scale, with about one-half of the employees of the centers coming from the patient population.41 Although Geiger and others initially conceived of the NHC as free health care institutions designed to provide no-cost services to everyone within a community regardless of income, a 1967 congressional amendment to the Economic Opportunity Act linked NHC full-pay eligibility standards to Medicaid eligibility standards. Patients with incomes above the Medicaid standard could use the NHCs on a sliding scale.42 One economist who studied the NHCs argued that the most successful programs offered health services to everyone within a geographic area in which the vast majority of residents qualified for free medical care. In those cases there was little stigma for using the program.43

Planners of the NHC programs also intended to provide continuity of health services for poor patients accustomed to fragmented emergency room or outpatient public health department care. As one evaluator of the NHC program explained, NHCs responded to “fragmented care that was the only care available to many poor persons” in the form of “chest x-rays, immunizations, VD control . . . the fragments in the outpatient departments with their multiple specialty clinics, the fragments of provider continuity, the fragments with regard to the availability of services at selected times during the day or week, fragments with regard to the family, i.e., clinics that served only children, adults, [or] women” as was provided by most health departments and hospitals nationwide. Rather, the NHCs promised “comprehensive care in the concept of the neighborhood health center . . . implemented by providing single-system access to a full array of primary health care for families.” Most health centers housed a general practitioner, a pediatrician, and an obstetrician under one roof. The reasoning behind this design was to prevent patients from shuttling among disconnected clinics or specialty medical departments without any rational coordination of care.44 Specialists not housed at the NHCs were available by referral. Comprehensive services at health centers often included drug treatment, mental health services, food assistance, and dental care.45 Legal aid and job placement services were also common.46

The two fundamental goals of most health centers were to provide medical care to poor Americans and to involve those using the facilities in the creation and management of those same health care programs.47 The OEO required health centers receiving funding to link to a local organization in order to bring community residents into the health centers as more than patients. These organizations took a variety of forms: “county medical societies, medical schools, state departments of public health, private group practices, hospitals, and a variety of community organizations.”48 The centers were most often administered by community hospitals, medical schools, and health corporations, but they were also run by health departments and nonprofit groups on occasion.49 Consumers of health center services were sometimes the force behind the creation of particular centers.50 Private and community foundations also supported NHCs that had not garnered OEO support. The Student Health Organization (SHO), a national organization of politically progressive medical students, created free clinics grounded in the counterculture movement and the student-populated New Left movement. Nationalist organizations such as the Black Panthers, the Young Lords, and the Brown Berets also provided linked health and community services that emphasized the relationship between health and broad social justice inequalities. The Black Panthers, in particular, with strong institutional ties to federal War on Poverty programs, criticized government-sponsored health centers for not doing enough to involve and empower the communities they served.51 In the next decade feminist organizations would foster their own related health reform movement that would support health clinics across the nation dedicated to providing services to women.52

OEO guidelines for federally funded NHCs required that at minimum 50 percent of membership on NHC “advisory boards” be comprised of local individuals or one-third of a full-fledged “governing board.”53 By 1971 residents were approximately 50 percent of the staff at the centers.54 Some NHCs pursued community hiring vigorously; the South Bronx NHC composed a staff almost entirely of community residents.55

The community board requirement and practice of hiring from within communities generated the most controversy for the Neighborhood Health Centers. Physicians and other professionals sometimes worried that local residents and consumers would demand unrealistic services or try to make medical decisions as part of an NHC community board. Although there is no evidence that community boards tried to influence medical decisions, they often made nonmedical recommendations. For example, one majority-black community board required physicians and nurses to live in the same neighborhood as the health center. They successfully recruited white physicians to move into the community and work at the health center. Another majority-Latino community required staff, including physicians, to learn Spanish in a six-month period. They only hired staff willing to commit themselves to this task. Community groups often argued for particular hours of service that made sense for a neighborhood or made geographical recommendations to project directors. Often residents demanded that medical staff be more sensitive to the community.56

Residents also often became involved in NHCs as community health aide workers responsible for outreach to poor families unaccustomed to using preventive medical services. Some of these aides trained to provide basic home health services for patients unable to travel to an NHC. Professional development for these community workers also became part of most NHCs.57 Thomas Bryan, director of OEO’s Office of Health Affairs, which administered the NHC program, explained that “[i]f the professionals can continue the dialogue, they generally discover that the consumers and providers become more sophisticated and a better working relationship will evolve.” Dr. Joyce Lashof, codirector of Mile Square Community Health Center in Chicago and director of community medicine at Presbyterian St. Luke’s Hospital, also supported community input. She argued, “You absolutely must be able to come through with solutions to honest demands made by the poor . . . you must also be completely honest about what you can and can’t do, giving the people all of the alternatives and choices available to them.” Thus, a real collaboration would ideally evolve between community members and administrators and physicians delivering the services. Training for both community workers and employees from outside of the community made collaboration easier. Both had to learn to bridge differences and negotiate priorities.58

According to Geiger, any real community collaboration required an evolutionary process that did not always succeed. Community control did not just happen because medical administrators said they wanted it. Geiger observed that many NHCs first established anodyne community boards without any real authority and usually comprised of the most vocal or visible community leaders. He recounted that one community board member in Boston accused administrators of failing to foster any real collaboration. This man shouted out at a meeting, “I understand your idea of this partnership! I’ll provide the illnesses and you’ll run the services, just like always.”59 Over time the community board sometimes agitated for more concrete influence over the NHC policy. Geiger argued that this agitation often caused conflict between professional administrators and community leaders with different priorities for the health center. Understandably, health professionals were not accustomed to negotiating their programs and budget choices with nonprofessional community members. Through negotiation of this conflict, actual collaboration sometimes occurred between community boards and medical administrators. If a community board established bona fide shared power with administrators through conflict and negotiation, they also had to build real ties of communication with community residents. Again, this took sustained commitment and time.60 Hatch warned that community involvement should not be assumed because residents joined community boards. He asserted, “Simply to place poor people on boards-of-health programs and expect them to compete with the traditional health care industry was foolhardy.” He continued, noting that residents “frequently lacked certain technical knowledge and resources, as well as the accepted language with which to gain even more.”61

Geiger noted that the Columbia Point Health Center tried to build community support—and failed—with a series of living-room meetings about health care and related needs. But after about forty to fifty such meetings, the community organizing stopped. Without sustained efforts, connection with the community and its needs never solidified. Other accounts suggest that violence and crime in the housing project also made community organizing difficult.62

In Mound Bayou, by contrast, community action staff spent an entire year meeting with local residents “in their homes, in churches, in schools, and on the plantations in the area. This staff literally knocked on the door of every house in northern Bolivar County inhabited by a black family.” They found that community members wanted more than health care; they needed basic services, jobs, better housing and education, and food. Residents expressed these needs over the course of two years of community organizing as staff integrated residents into the process of creating the health center at the foundation.63

Before they ever commenced knocking on doors and meeting with residents to define the health problems that residents most wanted to solve, in 1965, Tufts-Delta Health Center founders carefully chose to locate the rural center in the Delta community of Mound Bayou, an all-black community of twelve thousand residents. Freedman Isaiah T. Montgomery had founded the town in 1887. Since its founding, Mound Bayou had been unique in the Mississippi Delta. Emmett J. Stringer, a leader with the National Association of Colored People (NAACP) at the time of the 1954 Brown v. Board of Education Supreme Court decision, recalled that growing up in Mound Bayou had a very positive influence on his development as a “race man.” He said, “Having seen black mayors and bankers and policemen and superintendents of schools, I knew what was possible, probable, and desirable.”64

Yet, Bolivar County had long been one of the poorest counties in the nation. The infant mortality rate of the county was astoundingly high in the 1960s, as about sixty per one thousand infants died before their first year. (As a point of comparison, that is about the same rate as Burundi, Uzbekistan, and Nepal; the U.S. rate is currently 6.8 per thousand.) Because the county was ensconced in the Delta region of Mississippi, sharecropping and cotton production had employed most of the residents of Bolivar County. But as cotton production mechanized, sharecropping families found themselves without any means to earn even a meager livelihood to replace that provided by cotton. The residents of Mound Bayou lived on a median annual income of less than one thousand dollars per family per year and unemployment was over 50 percent. By all accounts they also suffered from a severe lack of health care as well as poor sanitation, including unprotected water supplies—70 percent of the population was without a clean water supply. Mound Bayou residents suffered from a lack of adequate shelter as well—some 90 percent of dwellings were unfit for human habitation.65

During the initial stages of planning for the center, Hatch explained that he first met with community leaders to defuse opposition to the project, particularly among local medical practitioners who were fearful that the health center would displace their practices. To ensure community involvement at the very beginning of the project, staff immediately incorporated local people into the organization by recruiting residents of Mound Bayou and Bolivar County to go door to door to community homes, churches, and schools to discuss community health needs. They also established a relationship with a local bank, explaining that “the center’s million-dollar annual funding and cash flow would be deposited in whichever bank opened a branch in a Black community, hired residents as tellers instead of janitors, and engaged in fair mortgage loan practices.”66

From these efforts, ten local health associations organized into the North Bolivar Health Council and eventually became the advisory committee and then governing board for the health center. The North Bolivar County Health Council was comprised entirely of African American community residents, all of whom were also patients at the health center. The Health Council defined priority health needs to be addressed by the neighborhood health center. Priority health requirements ranged from improving access to drinking water in a community where people had to walk three miles for clean water to health care for children and the elderly.67 Community members subsequently used political experience gained with the health center to enter local politics—six local organizers that Hatch had recruited to find out about community needs went on to become mayors of majority-black towns in Bolivar County.68

Community members involved in the Tufts-Delta Health Center in Mound Bayou expanded the traditional idea of health care by pointing out that food, jobs, and housing were fundamental requirements for good health. For Geiger and other organizers of the project, it was essential to the success of the clinic that local people identify health needs for themselves. That these were not always traditional health care needs was not a problem. The clinic founders believed that they needed to respond to health priorities set by the people themselves. By 1969, seven thousand black residents of Bolivar County were involved in implementing the services sponsored by the health center; these were services the community members had created for themselves.69 Geiger and Hatch also recruited black professionals from the North to work at the health center. These included ten doctors and ten nurses. Social workers, a psychologist, a nutritionist, and a pharmacist also counted among professionals recruited for the clinic.70

By attending to what local people needed and wanted, the community clinic improved upon more traditional medical provision in the rural South. Geiger wrote that the Mound Bayou clinic provided “the essentials of community-oriented primary care: family health care teams; community organization and health education; the training of local workers as family health aides, environmental sanitarians and health [educators].”71 Health care was much more than seeing a doctor for these community activists. It meant building a strong economic and social base for the community as a whole.72 A community vegetable garden became a 500-acre farm cooperative founded by twelve hundred families in the region. “The first farm co-op of people who don’t own farms,” Geiger commented, recognizing that the vast majority of Delta residents lived on some of the most fertile land in the country but did not produce food for their own consumption. The sharecropping system, shaped by deeply embedded and historical race and class hierarchies, fostered malnutrition in rural areas where local blacks had almost no control over what was grown on the land they inhabited.73 In just over seven months the co-op grew more than one million pounds of food and effectively ended hunger in the area. As Geiger explained, the most important lesson to impart from the Mound Bayou experiment to health care providers is that “your [health care providers’] priorities may not be those of the people you are concerned with. . . . People who are concerned with survival are going to be worried about that before they are concerned with tuberculosis. They are going to be concerned with housing, jobs, food, their kids, and some other things.”74

Survival had become a problem for Mound Bayou residents, particularly since mechanization of the cotton crop in the mid-1960s had left thousands of families with no income. A 1967 investigation of the health of Delta residents by a team of six physicians discovered widespread malnutrition among children. They reported that children were dying from hunger and malnutrition. Geiger wrote prescriptions for food to make the point that traditional public health measures such as vaccinations or treatment for tuberculosis would not cure a fundamental need for basic socioeconomic measures like food and income.75 Geiger explained,

We decided that we had to do something more than keep treating individual cases, and that the first problem we had to address was the lack of food. And so, in the absence of any other resources, whenever we saw a child suffering this combination of infection and malnutrition, we wrote prescriptions for food: RX, so much milk, so much meat, so many vegetables, so many eggs.76

By the 1950s and 1960s, as the cotton harvest mechanized and white plantation owners saw no economic incentive to provide medical care to blacks who lived on their land, many rural African Americans went completely without health services. Often they were also without basic transportation to get to a hospital even if one existed in their area.77 Few white physicians worked in rural black areas, and those who did often neglected poor blacks. Hospitals that did serve African Americans often turned poor patients away if they could not pay. Health insurance was largely unavailable to blacks because of discrimination by national insurance companies like Metropolitan Life.78 As Dr. L. C. Dorsey, civil rights activist and director of the Delta Health Center in the 1980s, explained, “Doctors on plantations found conditions so unpleasant they didn’t want to treat African Americans. Health care for poor people and poor black people was dependent on home remedies.”79 Richard Hall, a reporter writing about the Tufts-Delta Health Center for Life Magazine, observed that “blacks in the farm country outside Mound Bayou were accustomed to suffering the pain of their illnesses until it became unbearable. Only then would they seek out a doctor. Even if the doctor was black, he would frequently demand payment on the spot; and if he was white, he would often only talk to them across a desk, asking questions.”80

There were other social factors stemming from within black communities that also prevented Delta residents from accessing institutionalized health care even when it was available. Many African Americans expressed a strong personal preference for local black midwives over white physicians. This preference can be traced to the legacy of African American health care practices under slavery, which included traditions of lay midwifery among African American women. These traditions continued into the Jim Crow period as black lay midwives still provided the greater part of health care for their communities. The preference for midwifery eroded, however, in the first half of the twentieth century through a complex interaction between public health policymakers and physicians who barred local black midwives from medical practice through a system of regulation and forced “retirement.”81 African Americans in the Delta were also frequently distrustful of white health care providers because of medical abuses—particularly after the Tuskegee (Alabama) experiment (1932–1972) and the high incidence of involuntary sterilizations were revealed in the 1970s. Distrust of the medical establishment needed to be addressed before African Americans would use mainstream health services in large numbers. As Dorsey recalled of the 1970s, “Black people were suffering from the aftershocks of the Tuskegee experiment. . . . I thought it would be real easy to tell people, ‘you got free health care,’ but many of them were suspicious.”82

The Tufts-Delta Health Center example suggests that African Americans needed to become agents in the provision of their own health care in order for health care institutions serving poor blacks in the South to succeed and thrive. Community control over the health center fostered a strong sense of personal and community empowerment by providing the opportunity for local blacks to command the expansion of an entire nexus of interrelated health care services that embraced reproductive health, sanitation, housing, education, and jobs. Empowerment was linked to the creation of services by and for the community, rather than the imposition of services on the community by outsiders. Local blacks also capitalized on their involvement with the health center and with professionals who could help residents pursue opportunities well beyond the area served by the health center. An office of education associated with the health center helped local students apply to college and professional schools and helped find information on scholarships. Health center staff also offered high school equivalency and college preparatory classes at night; these courses were accredited by the local junior college. Many of those who attended and/or worked at the health center went on to further their education elsewhere. Staff could also get college credit by working at the health center if they attended the local junior college. Others trained for professional jobs at the health center, such as librarian or medical technician or assistant. A few local employees went on to attend nursing or medical school or to receive training in social work, psychology, pharmacy, or education. The health center fostered an environment that encouraged the pursuit of opportunities that had been markedly absent from black Delta residents’ lives up to that point.83

Other health centers in the country also brought community members into the medical field by training local residents for jobs. The Mile Square clinic in Chicago employed 271 people, three-fourths of whom were local community members. Many of these local employees, as at the Tufts-Delta Health Center, were outreach workers hired to accompany a public health nurse on home visits. These visits were meant to attract “people into the center who have difficulty understanding the importance of health care.” Training for community members cost money, of course, but architects of the community health centers believed that community involvement as well as jobs that provided a living wage fostered community health.84 In addition to explaining the need for health care to a local population often suspicious of health care professionals, outreach workers followed up on missed appointments, helped people understand the importance of nutrition to good health, and aided people with problems associated with their welfare payments, housing, or jobs.85 An OEO-supported health center in King City, California, that served both local residents and migrant farm workers trained locals to perform x-rays and provide physical therapy as well as make home visits in Spanish.86 One example from the Martin Luther King Health Center in New York City, another OEO-supported NHC, illustrates the importance of these home visits. A five-year-old boy had appeared at the clinic six times in three months. A home visit revealed that his “apartment lacked heat, and the winter cold was leaking through a broken window. The family was also short on food and badly needed more clothing.” The outreach worker helped the family access welfare benefits that allowed them to heat the apartment and acquire clothing and food. The five-year-old could only get well after these linked socioeconomic problems were addressed.87

L. C. Dorsey’s interaction with the Tufts-Delta Health Center characterizes the way community involvement in medical services could help transform black people’s lives beyond simple health care provision. Dorsey was born on a plantation to sharecropper parents (just a generation removed from slavery) in Washington County, Mississippi. She grew up in neighboring LeFleur County without access to education or job experience except in the fields. As a teenager, Dorsey was a social activist—a self-described civil rights field worker—with the Council of Federated Organizations (COFO), the Student Non-Violent Coordinating Committee (SNCC), and the Southern Christian Leadership Conference (SCLC). From her involvement in the civil rights movement, Dorsey heard about the Tufts-Delta Health Center and was intrigued because she wanted to become engaged with a project that would be sustainable. She explained that she was hired to be a part of community health outreach with the center. Dorsey said that Hatch, at that time director of Community Health Action at the health center, wanted to give young people the chance to grow in the organization, so he hired people with little or no work experience. After a stint as an outreach worker, Dorsey applied to direct the community farm associated with the clinic. Again, she noted she had no direct experience but was given an opportunity to develop her skills on the job. She also utilized Delta Health Center resources to complete her high school degree at the local junior college. Dorsey made clear that her work with the health center helped build her confidence to the point that she eventually completed an undergraduate degree and attended SUNY–Stony Brook for her master’s in social work. Ultimately she completed a Ph.D. at Howard University and returned to the center to become its executive director in 1988.88

Most of the Delta Health Center patients were women, children, and elderly men. Because there was so little paid labor in the South, many young men migrated north to find jobs. As a result of out-migration, the average age of Mound Bayou residents was only about fifteen, and the average age of men in the community was about fifty. Thus, women and their children were very much at the center of the Tufts-Delta Health Center as both patients and workers.89 With so many women in the community, obstetrics and gynecology were essential specialties at the health center. Two white nurse midwives, one a nun, Sister Mary Stella Simpson and Asa Johansen, both of whom joined the clinic when it opened its doors, worked in this area. The first black female obstetrician/gynecologist to practice in Mississippi, Dr. Helen Barnes, also joined the center in 1968. When she arrived at Mound Bayou, Barnes set up a program for prenatal care, delivery, and contraceptive services, which was supported after 1970 with federal funds accessed through Title X, a program created by President Nixon to promote family planning among poor Americans.90 Born in Mississippi, Barnes left the state to earn her medical degree from Howard University in Washington, D.C. After completing her degree in 1958, she returned to the Mississippi Delta to serve as one of the few black general practitioners in Greenwood, Mississippi. After returning north to complete specialty training in ob/gyn at Kings County Hospital in Brooklyn, New York, she joined the Tufts-Delta Health Center.91

Like Geiger, Barnes discovered that she could not address ob/gyn or infant health without addressing the larger environmental and economic problems that faced the community. She recalled that “[w]e had pediatrics and surgery, but I also found out that it’s all right to practice medicine and deal with sanitation and feed people—write a prescription for evaporated milk.” Like general health care, ob/gyn and child health services could not be limited to a narrow conception of medical practice. The practice of medicine necessarily expanded to embrace the environmental and economic problems of the Mississippi Delta community. Barnes continued, “I delivered babies every day and night and the nurse midwives would go out to do home visits—take care of the babies. [They would] look and see if they had screens and if they didn’t have running water they would dig a well.”92 Thelma Walker, another local woman who became the nursing administrator of the center, added,

If a nurse in the field finds a home without a water supply—out go the sanitarians and engineers with the well digger invented right here at the center and they dig a well in half a day. If there are rats coming through the floor, we exterminate them. A leaking roof? A privy falling down? Out go workers from the center—and these are local people—to patch the roof, build a new privy or take healthy adults tools from the tool bank we’ve scrounged together so they can make their own repairs.93

Although there was no women’s health movement in the late 1960s in the Mississippi Delta, there is abundant evidence that African American women responded positively to contraceptives when they were made available. Dr. Barnes distributed large numbers of contraceptives as part of a “community health improvement program” supported by federal Title X funds. Barnes explained that for many poor black women this was the first time they had been introduced to any kind of family planning. For the most part, she said, black women responded positively to the idea that they could limit their fertility using contraceptive measures. She recalled that women also came to her to be sterilized when they felt they no longer wanted to bear children. Her experience confirms other evidence that African American women wanted to control their fertility as long as they could do so voluntarily.94

At the same time, in the late 1960s and early 1970s, many African Americans, including black nationalists, but also other women of color involved in the burgeoning feminist movement, viewed federally sponsored birth control programs as genocidal. Federally funded family planning programs were often associated with ideas of population reduction and population control rather than with notions of creating healthy communities. Black women were particularly adamant that birth control and abortion services needed to be accompanied by other health services that allowed black families to bear and raise the healthy children they wanted. Any emphasis on population reduction as a solution to black poverty made many African Americans very suspicious.95 As Barnes noted when I asked her why blacks were suspicious of white health care providers, “You can get kicked in the shins only so many times before you decide that you won’t trust people anymore.”96 To gain the trust of the populations she worked with, Barnes explained, we “set up a clinic in a community and found more people came to the clinic year after year after year because we were proving to the community that we were going to stay and do what we said.”97

A collection of letters written by Sister Mary Stella Simpson, one of the nurse-midwives at the health center, serves as a particularly cogent example of how women’s health, in particular, needed to be understood in conjunction with larger community development needs. Simpson arrived in Mississippi in 1966 from Evansville, Indiana, to work at the newly opened Tufts-Delta Health Center. As a native of rural Arkansas, Simpson said she “was very familiar with the kind of poverty . . . found in Mound Bayou.” Her letters paint a vivid picture of health conditions in the Mississippi Delta during this decade.98

One letter reveals the extent to which African Americans in the Mississippi Delta lacked even basic necessities such as adequate shelter, food, and clothing, as well as health care and access to education. Simpson recognized these as fundamental problems that could not be separated from her primary task of providing ob/gyn care to poor women:

Today was my first day for [obstetrical/gynecological] home visits. . . . On the very first one I had to come back to town to get milk for a baby. He had finished his last bottle. It had gotten really cold, and the 14 people in that family all congregate in one room around a small wood burning stove. . . . The children were all barefoot, therefore could not go to school. The parents have no way of getting shoes for them since they have no income. . . . A year old baby was very ill with diarrhea—had it for a week. So I had to drive the mother with all [her] six children to the clinic. The baby had to be hospitalized.99

Another letter addresses the extraordinarily poor housing occupied by Delta blacks. Again, inadequate housing could not be separated from this particular woman’s need for prenatal health care: “I went into a shack out in the country on one [prenatal] visit today and found the ceiling was made of cardboard boxes and the roof leaked badly. What a sight! I did the prenatal exam as if this situation was a daily occurrence. ‘We’ll fix it when it stops raining,’ says the husband as he sweeps the water through the cracks in the floor.”100

Through her letters written home to her convent sisters, Simpson provided a detailed overview of the persistent and basic health problems confronted by poor African Americans who were served by the Tufts-Delta Health Center. Within days of her arrival in the Mississippi Delta, Simpson learned that ob/gyn care was not enough to improve the lives of the women and children she treated. As Geiger, Barnes, and Dorsey had already noted, Simpson found she needed to supply a nexus of health-related provisions such as sanitation, screens on windows to keep out mosquitoes, other basic housing improvements, clothing, nutritional information, and food. Without these vital necessities, the provision of any medical care was pointless.

Persistent problems recorded by Simpson were lack of food, inadequate housing, and inadequate clothing. In one letter she wrote, “The last place I visited was the worst ever. The dogs and cats go and come through the walls. It has a high front porch and an old washtub turned upside down for a step. I was scared stiff to put my weight on it, but it held. The mother and daughter were wearing rags held together by safety pins and had bare feet.”101 The lack of basic necessities was so profound that health center doctors, nurses, and nurse-midwives spent much of their time helping to find food and clothing, repairing screens on windows, pressuring landowners to provide better housing, and connecting patients with welfare entitlements such as food stamps.

Women also lacked basic health education, which compromised the health of their children. Although the health center midwives and physicians, including Sister Simpson, encouraged breast-feeding, few women practiced it at first. Physicians at Taborian, the local Mound Bayou hospital, discouraged women from breast-feeding their children because it was viewed as inconvenient (for the hospital that had to support women who breast fed, not the mothers). This left women with no option but to use formula, which required sterilizing bottles and finding clean water. Many homes on the white-owned plantations and farms in the region were without running water or a well. Some families used water from the bayou until it dried up in the summer. Some families were also without the means to boil water, and women often didn’t know that a bottle could not be rinsed and reused. Because of the unsanitary conditions, diarrhea was a constant problem with small children and a major cause of high infant mortality.102 In 1960 the infant mortality rate in the Mississippi Delta was more than sixty deaths per thousand live births, more than twice as high as the rate for white infants.103 This number was high compared to the national rate in 1960, which was about forty-five deaths per thousand live births for African Americans and just over twenty for whites.104 Although both white and black infant mortality rates had been declining nationally since the mid-1930s, the rate of decline for whites was 3.2 percent annually, while the rate of decline for black infants was only 2.6 percent.105

The women in Mound Bayou and Bolivar County were very enthusiastic about breast-feeding when they were given some coaching as to how to get started. Because good mothering is something that is learned and not instinctual or natural, new mothers often need to be shown how to breast-feed their babies.106 In the past it had been grandmothers and granny midwives who passed on this knowledge. Without these traditional health care providers, however, women in Mound Bayou and surrounding areas were often reliant on indifferent physicians and hospital staff until the community health center was founded. Sister Simpson recorded the enthusiasm for breast-feeding she witnessed among the new mothers:

We are starting to see results! Breast-feeding is beginning to catch on. We hope to have 100 percent of our mothers feeding this way before the year ends. The mothers enjoy our classes, too. . . . We seem never to get away from the sessions. . . . They ask questions for hours! One of the mothers delivered her baby only a few days before the next class. She didn’t want to miss it, so we went to her home and had class there!107

For many of these patients, a home visit by a nurse midwife was their first encounter with a health care practitioner. Many women had received no prenatal care, had never had any sort of medical care as children, and bore their children without any medical support. Simpson also confirmed reports that some doctors and hospitals in the area that did provide care for poor African Americans were neglectful or inadequate for the population. In one case a mother took her eleven-month-old baby who would not eat to two different doctors before Simpson helped her to get her child into a hospital that would feed the child intravenously. Another eighteen-year-old patient was due to deliver her baby any day and was experiencing preeclampsia. She had extremely high blood pressure and protein in her urine but had never been seen by a doctor.108 Simpson also cared for a child whose hand had been badly burned and had healed into a fist—the child would remain handicapped for the rest of his life—because a neighborhood doctor had neglected to treat him properly.109 Sister Simpson noted that prenatal care was seldom the only care given on a home visit: “If the prenatal exam was the only thing we did on such visits, they wouldn’t take so long. But when you see a little one with impetigo all over his face, you doctor him, which often takes a couple of hours.”110 As Barnes pointed out, “Medicine may be the way we got in the door, but medicine is not the number one priority. There are other priorities; food is number one and then a way to make a living.”111

The clinic quickly transformed the health of the population in the area served by the Tufts-Delta Health Center. When the health center was first established, clinic services and training for community staff occurred in an abandoned church parsonage and in an old movie theater in town. After about a year, a new building was built for the health center. By 1969, the clinic was able to provide hospital equipment to patients in their homes when there was not enough space to accommodate patient needs at Taborian Hospital. Prenatal and postnatal care both improved dramatically over the first three years of the clinic’s existence. Thelma Walker reported that ob/gyn care had grown from almost nothing in the community to a majority of pregnant patients attending the clinic before the fifth month of their pregnancies. Many of these women gave birth at the hospital or at home with a midwife in attendance and were then followed up postpartum at the health center. Their infants received care from birth onward. Walker explained that it was “quite a change . . . from the days when Sister Mary Stella and Aase [sic] Johansen saw many mothers for the first time when they were ready to deliver—or had delivered—and from the time when little children never saw a doctor or nurse until they were so ill with diarrhea or pneumonia that it was touch and go to save them.” She added that the “two nurse midwives have helped in prenatal care or delivery of over 100 babies, all living, many at home, but now most mothers have their babies in the hospital.”112

Ultimately, the Tufts-Delta Health Center brought poor blacks in the Delta the basic and preventive health services that were available to most other populations in the United States by 1966. But, unlike with most other hospitals serving the poor in America, in Mound Bayou the poor provided and managed much of their own health care. The health center workers, many of whom were drawn from the local population, including the physicians, nurses, nurse-midwives, nurse’s aides, sanitarians, and health outreach educators, were black women and men who understood that African Americans had been neglected and even abused by mainstream (white Jim Crow) health provision in the past. Clinic staff also addressed fundamental factors contributing to ill health that few people had defined previously as legitimate to a medical practice. As Dorsey explained, they had created a farm collective because they believed that the only antidote to hunger was food.113 Lack of food was a medical issue. Geiger pointed to the success of the cooperative farm: “In one spring and summer, they have grown one million pounds of food, enough to end hunger in Northern Bolivar County—sweet potatoes, Irish potatoes, snap beans, butter beans, black-eyed peas, collard greens and the like.”114

Certainly, a targeted focus on funding and delivery of health care to address health problems among the poor helped bring medicine to many patients never before seen by a doctor. But money is not the only reason many of these programs succeeded. According to Dr. Joseph English, administrator at HEW, some federal health care programs were unsuccessful despite targeted funds. He noted that $.5 billion a year went to fund grant-in-aid programs in Alaska but did little to alleviate the vast health problems in that state, particularly among Native Americans, who had some of the highest infant mortality rates and lowest life expectancy rates in the country.115 A Neighborhood Health Center in Lowndes County, Alabama, however, did demonstrate success. Lowndes County, like the Mississippi Delta, was one of the poorest places in the country, without jobs, adequate roads, housing, or any health facilities before the NHC arrived in 1969. The county had only three doctors, one of whom was in his late seventies. Locals involved with the health center pointed out some fundamental barriers to fostering good health among the poor that needed to be addressed for the health center to succeed. These included locating health facilities within walking distance or providing transportation to clinics. Also, showers and coin-operated laundries needed to be in health stations so that individuals could wash before seeing a doctor. Many local individuals felt too embarrassed to see a doctor without having washed and in dirty clothes. Other innovative solutions included a sewing machine at a clinic so that those without adequate clothing could make or repair clothes; another station included a kitchen in which nutrition demonstrations took place. As in Mound Bayou, patients were seen by nurses and community health workers recruited from the area.116

The difference between Alaska and Lowndes County or Mound Bayou was not money flowing from the federal government into a poor and underdeveloped region. Rather, the difference was in the design of the programs delivering the services. A comprehensive set of linked services planned by those who needed the services achieved good health for the individual and the community because locals were involved in communicating which barriers stood in the way of their health. Some of these barriers were transportation, cleanliness, housing, jobs, education, sanitation, and nutrition, and they all needed attention. Sometimes that attention needed to be tailored to a particular community.

On the whole, NHCs were praised for successfully achieving their goal of providing comprehensive health care and linked services to the poor in the 1960s and early 1970s. They received broad congressional support and continued funding even after other War on Poverty programs were dismantled during the Nixon administration. A 1971 evaluation of the NHCs also indicated that they had a significant impact on ideas about health care delivery within the medical establishment. The NHCs were part of a shift in health care delivery towards preventive services, which gained support as government agencies looked for ways to cut public health spending while also promoting a healthier population. The American Public Health Association, for example, began to increase its emphasis on primary care as the successes of NHCs became known. Although at first skeptical, the American Medical Association and state and local medical societies also expressed support for the NHCs. One public health evaluator writing about the health centers noted that papers delivered at AMA meetings “have all but endorsed the concept [of NHCs] and have at least moved to the point where they encourage local medical societies to participate in, if not endorse, these projects.”117 Evaluators also found that NHCs were cost effective. On the whole they were no more costly dollar for dollar than health care provided in the private sphere, but they also offered an array of services not available among private providers.118 The employment of locals in the programs also helped support the argument that the NHCs offered economic advantages. With 50 percent of their staff from the neighborhoods they served, NHC supporters asserted that money spent on the health centers was a positive economic stimulus. The majority of projects provided curricular support as well as on-the-job training to foster local employment. These additional services incurred a cost, but arguably one that returned to the community as people became trained for employment.119

The NHCs, however, were not without their critics. Some black rural and urban physicians worried that the NHCs would compete for Medicaid patients.120 A 1971 exchange between Dr. Jack Geiger and Dr. Howard Levy of the Medical Committee for Human Rights (MCHR) and Health-PAC, a New York–based New Left think tank devoted to medical issues, also revealed a negative view of NHCs from a progressive point of view. This exchange revealed that not all members of the movement to transform health care in the United States were happy with the NHCs. Levy critically assessed the NHCs as tools of a medical establishment bent on collecting Office of Economic Opportunity federal dollars without delivering any real transformation of health care or empowerment of the poor.

Much of the debate over the value of OEO-supported NHCs within the movement for health care reform played itself out within the ranks of the Medical Committee for Human Rights and the Student Health Organization (SHO), an off-shoot of MCHR. In the late 1960s MCHR’s political critique of entrenched establishment medical services mainly targeted the American Medical Association (AMA). They argued that the AMA represented self-interested physicians who viewed medicine as a privilege for the poor rather than a right. Dr. Fitzhugh Mullan, a member of the Chicago MCHR and SHO, wrote, “[T]o many of us the American Medical Association symbolized medicine in America. Overfed and complacent, the ‘voice’ of organized medicine seemed completely self-serving and ignorant of the health problems that beset many Americans.”121 Forcing the AMA to end racial segregation stood as one of MCHR’s great successes. They pressed the AMA to expel medical societies that based their membership on racial or religious criteria.122

The AMA, however, was not their only target. Younger MCHR members, who often joined the SHO to distinguish themselves from the older MCHR, became active in health care politics in the late 1960s, after the organization had shifted away from its origins in the civil rights movement, the Mississippi Summer Project, and desegregation. The younger participants often identified as part of the counterculture and the New Left.123 Levy allied with this cohort of young medical activists. Geiger, alternatively, represented the older incarnation of health reform activists who cut their teeth during the civil rights movement of the mid-1960s and were more amenable to building partnerships among the federal government, established medical institutions, and local grassroots organizers.

Despite their differences, Levy and Geiger both wrote from the perspective of wanting to transform what they viewed as a bloated and ineffective medical delivery system that did not serve poor patients very well. Levy believed, however, that Geiger’s OEO-funded NHCs only made the problem worse by accepting federal “establishment” dollars and imposing an outsider’s will on local health care providers by tying medical schools and medical elites to local projects. Indeed, over 50 percent of U.S. medical schools had been involved in NHC projects. Levy wrote, “It could have been predicted that the interests of the professionals, not those of the people, would be preserved when medical schools, chasing after the federal dollar, boldly stepped into poor communities, medicine bag in hand.”124 Levy argued that real experiments in community-driven health care delivery could be found in Black Power clinics provided by nationalist organizations like the Black Panthers. He also pointed to a critical letter that appeared in a local newspaper written by a Mound Bayou Black Power group opposed to the Tufts sponsorship of the health center in Mound Bayou as evidence that local blacks were not supportive of the project. Levy suggested that architects of the Tufts-Delta Health Center, Geiger in particular, never intended to alter medical delivery significantly. Rather, he believed that because the health center existed with federal financial support and medical professional guidance from mostly northern and white outsiders, it could not represent any real transformation of health care for the poor. It was, instead, an example of a kind of medical missionary project that maintained hierarchies between medical administrators/physicians and the recipients of care.125

Geiger countered that the Black Power group in question was never representative of the Mound Bayou community. They were an assertive group of activists who put themselves in the public eye, but that in no way gave them community authority. Instead, he noted, the Tufts-Delta Health Center had acquired “a staff and leadership that is 95 percent Black and 90 percent from Mississippi—and those percentages include the professionals: Black health center director, business administrator, clinical director, director of environmental health, social services director, director of training, and Black youth organization leaders, southern pharmacists, nurses, sanitarians, data processors, and three of the nine physicians.”126 He continued, asserting that locals “organized themselves first at the grassroots. . . . And in any given month 700 people come to a health association meeting.”127

Yet, in his critique, Levy raised important questions about the OEO-sponsored health centers and the extent to which they could provide real transformed medical care that not only expanded resources for the poor but also fundamentally changed the way health care was provided. Levy and Geiger fundamentally disagreed as to whether OEO-supported NHCs were the proper vehicles with which to meet their common goal of creating a health care system that no longer neglected the poor. Levy argued that storefront clinics provided by groups such as the Black Panthers were better examples of reformed medical institutions for the poor because they were funded and operated entirely by black activists (although they also employed white medical professionals from entities such as the Student Health Organization to staff the clinics and raised funds from white supporters). Geiger countered that these were patchwork measures and largely ineffective because their services were so limited. He believed that federal dollars linked to an established medical delivery system in the form of hospitals, medical schools, and local departments of public health could be effectively utilized by local health care activists to achieve successful health reform.128

Most examples of SHO and Black Panther attempts to provide clinics for the poor confirmed Geiger’s criticism. White volunteer medical students who provided medical support in SHO summer clinics (which did receive federal funding through OEO) in poor urban areas and in Black Panther clinics often found that they garnered important educational experience from the work but did little to change overall medical provision for the poor over the long term. A handful of clinics set up to serve the poor, most of which, like SHO summer projects, were also temporary, could do little to transform a medical system that failed to provide for the vast majority of the poor in both large cities and rural areas. SHO disbanded its summer clinics for this reason.129

Levy’s critique of and Geiger’s support for the NHCs hinged on what each meant by community control and, specifically, on whether they thought that involvement by the “establishment” negated community control. Did community control necessarily mean that white professionals and federal government support needed to be absent? Geiger insisted that the resources held by professionals, medical institutions, and the federal government were too important to reject. He wrote,

Those resources are now in the hands of the Establishment institutions—the medical schools, the hospitals, and all the rest—and the funds needed to operate significant health services must come from the Establishment, and overwhelmingly from government itself. These institutions are now, properly, damned for their racism, their elitism, their indifference and hostility to the community, their exploitation of the poor, and their refusal to surrender even a share of their control to community/worker groups. But what if they are dragged by the community, or the workers, or the students, or some of their own professional staff into primary care and community action and community service, or even into new institution-building under community control?130

If we accept Geiger’s assertion that the presence of the “established” medical and government institutions did not by itself hinder health care reform, did NHC programs foster a real partnership between traditional medical providers—public health administrators and medical professionals—and local poor residents and consumers of health care? From evidence gathered for this chapter, it appears that the NHCs were mostly successful in their effort to involve the community in health care provision and in broadening the meaning of health care to better serve the real needs of poor communities. Much of that success, however, depended on the quality of community representation at a particular NHC. Hatch explained that “OEO programs were often planned as if poor communities had no viable social organization or structure. They, therefore, sought to create or sanction new structures rather than to conduct a hard analysis of what existed.”131 Geiger agreed with Hatch that community boards at NHCs could be more or less effective depending on how representative board members were of the local community. He also asserted that community worker involvement in the clinics impacted medical delivery much more consistently than did community board involvement. Medical administrators reported that community outreach workers often improved contact with and design of programs within a particular neighborhood. Maximum utilization of community workers, however, also required adequate training programs, which were also unevenly operated at the NHCs. In some of the more successful cases community workers were hired for nonprofessional reasons such as their intimate knowledge of the community but then trained to develop new career tracks as professional employees.132

It is very unlikely that such an extensive program of health care reform could have been realized or even minimally successful without strong federal support and some help from established medical providers.133 The program required both money and medical expertise ideally guided by those who most needed and used the resources but provided in dialogue with professionals who delivered technical expertise and services at least until community workers could be trained to deliver services themselves. A less successful (and much smaller) health care reform effort that took place in 1970 at Lincoln Hospital in the South Bronx, a city-run hospital affiliated with Albert Einstein College of Medicine, lacked both federal funding and broad support from the medical administration. This program’s failure to establish lasting reform lends credence to Geiger’s contention that some federal money and established medical involvement combined with community input were essential for any real sustained change.134

The Young Lords, a Puerto Rican nationalist organization modeled on the Black Panthers, and other activists involved in Lincoln Hospital reform efforts shared the goal of improving health care and its delivery within a very poor community with multiple socioeconomic problems that deeply affected health. Originally built in the nineteenth century for use by freedmen and women, Lincoln Hospital had long been considered a woefully inadequate provider of charity health care to the mostly black and Puerto Rican residents of the South Bronx. The vast majority of health care providers and staff at the hospital lived outside of the South Bronx community and did not use the services of the hospital. By the mid-1960s, senior medical staff, residents, and interns at Lincoln hospital became affiliated with Einstein Medical College, improving medical care somewhat. Yet, Einstein interns and residents who rotated through Lincoln to complete their medical educations had little commitment to the Bronx community. Most of the young physicians were foreigners from outside of the United States who were only in the South Bronx to complete their medical training. Furthermore, senior medical staff on the faculty at Einstein Medical College utilized the patient population for instructional purposes, often with little or no sense of obligation to the community.135

Health care reform activists contended that community involvement needed to be at the center of any reform effort so that Lincoln would serve the health needs of the neighborhood. Several protests occurring in 1969 and 1970 involving Young Lords and other community activists attempted to further this goal. In the first protest in July 1969, community workers who had been trained in the Lincoln Community Mental Health Program, operated out of an old nurses’ residence at the hospital, focused on gaining more community-worker control over the mental health services. Cleo Silvers, one of the staff protesters, recalled that they demanded that psychologists consider that poor people had very specific problems that could not be solved by middle-class theories of mental health care. They called for the replacement of the two psychiatrists who ran the program and for a section of the mental health unit to be devoted to welfare and poverty issues. After the protest, the worker/activists became more involved with local branches of the Young Lords and Black Panther Party.136

Nearly a year later, in June 1970, at Lincoln Hospital, another health care reform effort was organized by workers, community members, and the Young Lords. This diverse group called themselves Think Lincoln. To illustrate their demands for more community-worker input into hospital policy and health care delivery, activists staffed community complaint tables in the lobby of Lincoln Hospital. As health care reform activist Fitzhugh Mullan recalled, “The complaint table was intended as a mechanism to stimulate patient awareness and participation in the hospital.” Those who staffed the complaint table handed out leaflets and pamphlets about patient rights and community control. Signs placed near the table instructed patients to lodge grievances about the hospital at the table because it was “their hospital.”137

In many instances, activists at the table also acted as patient advocates. If a patient had complaints or questions that could be directed to a particular staff member, a Think Lincoln activist would help the patient locate the appropriate hospital worker or workers to find the answers. Often this system worked and many patients viewed the complaint table as a positive benefit that demonstrated that someone in the community cared enough to improve patient care at Lincoln. Some staff, however, felt under attack by the Think Lincoln activists in their advocacy role because they believed their competence was being questioned. At the same time, many staff supported the action as a way to better serve patients in an extremely busy and understaffed hospital.138

A group of pediatric interns and residents, including Mullan, who had specifically chosen to work at Lincoln because of his interest in community medicine, also sided with the Think Lincoln activists. This group of doctors called themselves “the Lincoln Collective” and had connections with both the Medical Committee for Human Rights and the Student Health Organization. The newly minted doctors believed the Think Lincoln tables provided “a ready-made political role for the Collective” as supporters of Think Lincoln community activists.139

Despite support from this group of young doctors on the house staff at Lincoln, as protests escalated at the hospital, divisions increased between the activists demanding greater community control and the Lincoln Hospital administrators who had no real interest in significant reform of health care delivery or community control. Without significant collaboration among health care activists, hospital administrators, and federal or local funds to sustain innovative programs, reform efforts were short-lived at Lincoln. Yet, even short-lived reforms revealed a demand for community involvement in health care delivery in the South Bronx that, while not met, clearly carried weight among young activist physicians, members of the Young Lords, and other members of the South Bronx community. One Young Lord, Carl Pastor, wrote of community control in the Young Lords publication Palante, “Who can better determine what’s best for ourselves than us? If this is the richest country in the world, why is it that this country is 13^th in the world in health care?”140 I focus in some detail on these particular protests at Lincoln Hospital to demonstrate that demands for community control thrived outside of programs sponsored by established physician-reformers and their federal government supporters at the NHCs.

The first escalation of demands for reform at Lincoln Hospital occurred on July 14, 1970, about a month after the complaint tables appeared in the lobby. This action involved a Young Lords’ occupation of the Nurses’ Residence (a former nursing school) at Lincoln Hospital for about twelve hours. The Lords presented a list of demands to hospital administrators that included a community preventive medicine program, a free day care center for children of patients and workers, a free breakfast program for children, health education classes, and a community-worker board to run the hospital. They asked why tuberculosis and lead poisoning, both preventable, were rampant in the South Bronx, suggesting that the hospital neglected the basic health needs of the community. The occupation garnered attention immediately. Police surrounded the building and the press flocked to publicize the Young Lords’ challenge to a city-run institution.141 Mullan recalled the experience from the perspective of a physician who lent his support to the community takeover: “The Nurses’ Residence suddenly had the fantastic, intoxicating air of a liberated zone. . . . The Lords had risen up and were telling the stories of the women and children waiting endlessly in the clinic, the old folks dying for lack of a Cardiac care unit, the humiliations of the Emergency Room, the flies, the pain, the degradation.”142 After police ordered the building cleared, the Young Lords and the interns and residents supporting the action left the building peacefully, ending the occupation. Permanent staff physicians at Lincoln generally did not support the action.143

The next protest and escalation of tension between activists and hospital administrators and permanent staff physicians revolved around the abortion death of a young Puerto Rican woman, Carmen Rodriguez. Sometime in the middle of July, Rodriguez had been diagnosed with rheumatic heart disease and told that a pregnancy endangered her life. She was scheduled for an elective abortion at the end of the month. The gynecologist performed a saline abortion, which ended tragically. Rodriguez died four days after the procedure. When it became apparent that a mistake might have been made at the level of medical malpractice, Think Lincoln and the Young Lords began to publicize the death as a murder. In response to the uproar over the Rodriguez death, Lincoln Hospital administrators announced that they would hold an open meeting with the community. The interns and residents involved in the protest called the meeting the “first People’s Clinical-Pathological Conference” (CPC) in reference to the medical school practice of analyzing difficult cases collectively. Mullan recalled the success of this People’s CPC: “At the least, it was a real and significant instance of physicians being called to account by community people. . . . [It] stood as a victory for community participation in the hospital.”144 Activist residents and interns shared Rodriguez’s autopsy records at the “People’s CPC” in order to assert the community’s right to access medical information that is usually kept by medical staff.145

At the CPC, the Young Lords, Think Lincoln, and other South Bronx residents asked questions of the senior staff physicians, including the director of the Department of Obstetrics and Gynecology. They wanted to know why a saline abortion had been performed on a woman with a disease that contraindicated the procedure. Think Lincoln and the Lords concluded that Rodriguez’s death, while not malicious, did stand as strong evidence that Lincoln Hospital provided insufficient and even dangerous medical care. They argued that the pivotal failure in this case had been lack of continuity of care, a common problem in an urban hospital catering to poor people without access to private physicians. Although Rodriguez had been treated for a drug addiction at the hospital and referred to ob/gyn for an abortion because of her pregnancy and heart condition, her case was unknown to the ob/gyn department. Better communication would have saved Rodriguez’s life. Think Lincoln and the Lords called for the ouster of the director of the Department of Obstetrics and Gynecology and for a worker-community board that would help design and oversee hospital policy. As a result of the protest, the director of ob/gyn resigned and an interim director took his place. Ultimately, however, the hospital retaliated against the activists, filing an injunction against the Young Lords and Think Lincoln that forced them to remove their complaint tables from the lobby.146

After the Rodriguez death, the hospital administrators took no actions to increase community control over hospital decisions although the Young Lords and Think Lincoln continued to organize around health care reform. The supportive residents and interns in the Department of Pediatrics experimented with increasing community involvement in their department. Mullan, another physician, Paul Bloom, and some former members of Think Lincoln helped organize a Pediatric Parents Association that would function like a Parent Teachers Association, allowing parents of young patients to have input in hospital policy. The group recruited parents in the hospital emergency room waiting area and in the pediatric clinic. A group of about ten parents met biweekly for several months to attend lectures about community health issues such as lead poisoning and to meet with physicians and staff. The parent group opposed budget cuts at the hospital and helped select the new house staff (interns and residents). After interviewing applicants, with particular attention paid towards candidates’ attitudes towards blacks and Puerto Ricans, the parent group made hiring recommendations to Dr. Helen Rodriguez, the new director of the Pediatrics Department and a strong advocate of community involvement in health care design and delivery. Less successfully, activist residents and interns also attempted to integrate worker input into the Pediatric Department. Nurses, secretaries, aides, and clerks, however, were suspicious of the physicians’ motives since they had never before been asked for their input. The nonphysician staff also brought their own hierarchy and disagreements among themselves to meetings, which inhibited free discussion. Unsurprisingly, many staff felt uncomfortable speaking freely among doctors in a workplace that had long operated along rigid lines of hierarchy and power. All of these factors contributed to a failed attempt to level hospital hierarchy.147

The physician residents and interns and the community activists, which included the Young Lords, pitted themselves against an intransigent group of hospital administrators who, in the end, stood in the way of any real transformation of Lincoln Hospital’s services, although they did succeed on a few fronts. Dr. Harold Osborne, an MCHR activist and intern at Lincoln, recalled that the interns were more successful at reforming the internship process than ending poverty-related health problems in the South Bronx.148 It was impossible to implement these sorts of reforms without some support from entrenched powers, even when those in powerful positions were also targeted for change. NHCs, with their federal mandate, congressional support, and national scope, were much more successful at bringing those with some entrenched interests in sustaining medical hierarchy—but also with interest in delivering quality medical care—together with community members who could help shape health center offerings to best meet their community’s needs.

Multiple studies support the contention that NHCs had many successes. One national study found that Boston, Chicago, and Portland hospital admissions were lowered for target populations. Researchers also noted a reduction in hospital stays as well as a reduction in the number of hospital days per capita. Several other studies showed a reduction of hospital admission up to 44 percent and a reduction of hospital days per capita from between 25 and 62 percent in communities with NHCs. Other studies of Medicaid users revealed that those using NHCs had 50 percent lower hospital rates than nonusers and reduced infant mortality rates, particularly among African Americans. These studies revealed too that when NHCs reduced hospital admissions, costs also fell in comparison to hospitals that employed high-tech solutions to low birth weight and premature births, such as neonatal intensive care units.149

There is less agreement about precisely which factors contributed to these improvements. Was it the geographical location of clinics in poor neighborhoods, the low cost to patients, the use of community outreach workers, or the use of community boards? It is outside the scope of this chapter to attach particular successes to specific reforms. It is also necessary to consider to what extent the NHC model really transformed health care delivery. Although health care and health improved markedly in neighborhoods with federally supported health centers, the solution was still hospital centered, technical, and entrepreneurial. Geiger, too, is critical of the form community health centers took over time as they lost their focus on community empowerment. He wrote, “After too few years the window that was open to expanded programs and community development began to close. This happened in part because of program costs and in larger measure because conservative national administrations were (to put it mildly) not overly interested in community empowerment and social change.” He explains that health centers became more traditional in their delivery of medical services rather than focusing on ending poverty or transforming social inequalities.150 Other critics of NHCs argued that although power was no longer held by individual physicians, it shifted to hospital corporations and insurance companies that made decisions about patient care rather than being distributed to community residents. Certainly, with the end of the War on Poverty, the gradual shift away from federal spending on social services in the 1970s, and the more onerous cuts in the 1980s during the Reagan presidency, community control of social programs no longer had many federal champions.151 Yet neighborhood health centers have continued to be a fundamental part of health care provision for the poor and uninsured in the United States. Today there are twenty million people each year who use community health centers. Twice as many will probably use the centers, with eleven billion new dollars from the Obama health care plan (the Affordable Care Act) and $2 billion in stimulus monies going to health centers. With this sort of long-term and future investment in community health centers, it is imperative that we attend to how and why health centers were created nearly a half-century ago and how and why they succeeded, even though success may have been uneven.

In the next chapter I turn to the feminist women’s health movement that grew, in part, from the health reform efforts of the civil rights and the New Left NHC movement. Feminists also built neighborhood-based health centers with local, federal, and private support, but they also challenged what they viewed as socially embedded gender hierarchies in health care delivery that were connected to a larger context of uneven social power between men and women. With less federal support than that garnered by NHCs, feminist women’s health centers also struggled to survive through the decade of the 1970s. When they provided abortions, their survival was threatened by a burgeoning and passionate anti-abortion movement.