Rutgers University Press, 2007 by Bonnie Lefkowitz
This new contribution in the series “Critical Issues in Health and Medicine” (edited by Rima D. Apple of the University of Wisconsin-Madison and Janet Golden of Rutgers University) from a veteran staff member of both the federal Bureau of Primary Health Care and the National Association of Community Health Centers provides juicy historical detail informed by decades of personal and professional relationships with a cast of characters still serving in the trenches of the U.S. community health center movement.
This welcome volume builds on a literature that is only now beginning to be written but is deserving of many more chapters. It picks up on Alice Sardell’s wonderful PhD dissertation, “The U.S. Experiment in Social Medicine: the Community Health Center Program, 1965-1986,” which chronicled the movement’s origins and subsequent political agility in successfully facing down the Reagan administration’s efforts to do away with the program through block granting.
Many of the health center founders interviewed extensively in this book are movers and shakers who now possess three to four decades of experience and who remain ensconced in their roles at community health centers across the country. A remarkable theme of grit, political skill and grassroots mobilization shines through the narrative. Lefkowitz makes the observation of a male predominance in those who run the health centers, but, speaking as a mid-career founder of one of the younger health centers (my own health center saw its first patient 10 years ago), I am struck by the large number of senior female health center executives who are as experienced and grounded in social justice movements as are the men.
Lefkowitz organizes the book into five major sections, each with its unique geo-cultural expression of the health center movement, and each home today to many thriving health center sites: Mississippi, Boston, South Carolina, New York City, and the Rio Grande Valley of Texas.
Health centers started in Mississippi and Boston, fueled directly by the Civil Rights movement from which they were initially indistinguishable (they were initially started as the health care arm of the Civil Rights movement). To this day, national health center meetings are strikingly diverse and multicultural. According to my conversation with historian John Dittmer, author of the classic “Local People: The Struggle for Civil Rights in Mississippi,” the Medical Committee for Civil Rights preceded the Medical Committee for Human Rights (MCHR) with the planning process for freedom summer, in 1963.
According to Dittmer, “Dr. Bob Smith of SNCC in Jackson sent out the call for medical support. Over a thousand [non-medical] volunteers were expected in Mississippi that summer, yet there were very few black doctors and very few white doctors willing to care for them.”
Interviewed by Lefkowitz in Chapter Two (“Mississippi: Where It All Began”), Smith estimates that, for the entire black population of 800,000 Mississippi residents, there were at that time only 25 to 30 black physicians in private practice. Smith recalls, “This place was sweltering in anger” following the June 1963 murder of Medgar Evers. Then as Dittmer has chronicled, “the murder of the three civil rights workers, including two young New Yorkers took place after the first MCHR planning meeting, and this totally galvanized the effort.”
Dr. Jack Geiger, who became the founder with Dr. Count Gibson of the first U.S. health centers, recalls that some of the north-south professional relationships forged during freedom summer continued with a much smaller number of northern physicians. “In December 1964, there was a meeting in Greenville of a bunch of us left-over civil rights types, the Delta Ministry of the National Council of Churches, a number of the Mississippi Headstart people, etc. It was at that meeting that I remembered my community health center experiences and training in South Africa and suggested that we try it here. Dr. Des Callan (a New York physician), Dr. Robert Smith of Jackson, the black physician who was the local linchpin of MCHR, and others, grasped the idea and offered suggestions and comments. At this time it was just a pipe dream; there were no federal grant programs for this at HEW or at OEO. I didn't contact OEO until January or February 1965, and ultimately it got funded as a research and demonstration project, the only way it could be.”
Geiger, at the time a member of the Tufts Medical School faculty, became the founder, with Dr. Count Gibson, of the first two community health centers in Mississippi and Boston. An interesting note is that Geiger acknowledges the Boston center was proposed only because Tufts would probably have refused to permit a project involving only a Southern site. At the Mississippi site, medical care was started alongside cooperatively-run education, transportation, farming and public health projects in which local residents were not only the passive recipients of government benefits, but were actively involved in restructuring their community around multiple basic human needs.
The health center program was written into law in the early 1970s, in order to protect it from the Nixon administration. The comprehensive health center program survived its second major political attack during the Reagan administration, ironically to become the darling of the Bush administration two decades later.
Today, the health center program has grown to serve more than 7 million Americans with medical, dental, mental health and substance abuse and pharmaceutical programs. As a unique favorite of the Bush administration, it has enjoyed increasing appropriations in the range of $200 million per year, while simultaneously undergoing (along with other federal health and human service programs) many corporatizing pressures. During the same period, increasingly restrictive coverage under many state Medicaid programs (the major revenue source for most health centers) and the new federal prohibition on Medicaid reimbursement for the care of undocumented patients have presented new sets of challenges for health centers.
An implication of reading Lefkowitz’s book is that continuity in the committed leadership of the overall movement and within individual health centers have played a critical role in maintaining the community orientation of health centers. As many discuss in moving and personal accounts, the life-changing commitment of many health center founders to the social justice movements of the 1960s and 70s carries them forward to this day. Political linkage between the health center institutions and the people they serve is a strong theme of the book, with many examples of the soul-searching struggles to maintain ethical, good-faith connections with the underserved populations and communities who have no other source for dignified health care. Some of these struggles are lost, but a surprising number continue to be won on both large and small scales.
Currently, defense of the community-based governance board requirement is an active project for many in the health center movement. Historically, Lefkowitz describes how this battle was previously fought and won; now it must be re-fought. Last year, the program failed to win Congressional reauthorization for the first time due to a proposal to allow demonstration projects by organizations that would be free of the longstanding program requirement for 51 percent controlling interest by actual patients on the governing board of each community health center. This effort was led by Catholic hospital organizations and quickly joined by other nonprofit and faith-based organizations serving large numbers of uninsured people but unwilling or unable to accept the rigorous community accountability that has always been a part of the foundation of health center governance.
Unwilling to accept this chink in the armor of health centers’ basic identity, the compromise was rejected and health centers have now entered a precarious phase of annual appropriation without authorization. In this, they have joined the ranks of other federal programs that resist restructuring of their basic mission (including federal family planning program and the National Health Service Corps). Health centers’ rejection of the “compromise” deal was made possible only by the political staunchness and numbers of the health center movement itself.
We should hope that Lefkowitz’s well-crafted book will be followed by many more to eventually recount all the stories of a feisty, durable American movement and a large and remarkable group of mostly unsung heroes, characterized by the same courage and resilience as the communities from which they draw their daily strength.
Sarah Kemble, MD, MPH
Executive Director
Desmond Callan Community Health Center
Turners Falls, MA