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
