More Than Medicine. Jennifer Nelson
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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