More Than Medicine. Jennifer Nelson
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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