More Than Medicine. Jennifer Nelson
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