Pholela Health Center in 1940 to serve a Zulu “tribal reserve” that suffered from desperate poverty. The emphasis at the clinic was not merely on individual health but on promotion of health for the entire community. Kark and other health care providers at the Pholela Health Center were principally attentive to environmental factors, including sanitation, as major contributors to the community’s ill health. They also focused on nutrition and basic preventive care. Everyone in the community was considered a patient regardless of his or her ability to pay for health services elsewhere. This model was so effective that Kark exported it to other South African health centers, including one at Lamontville, a housing project outside of the city of Durban. Kark and his colleagues targeted communities with “high birth rates, high death rates, a heavy burden of both infections and chronic disease, low levels of employment, low literacy, substandard housing and nutrition, and limited medical care resources.”28
In June 1964, as a participant in the Mississippi Freedom Project, Geiger connected his experiences with the health centers in South Africa to the desperate poverty he found in the southern United States. Geiger traveled to Mississippi in 1964 as a member of MCHR, taking time off from his new position on the faculty of the Harvard School of Public Health. During his month-long stint as a doctor-activist in Mississippi, Geiger found that African Americans lived in communities that were as poor and unhealthful as those he had seen in the tribal reserves of South Africa. He wrote that he “took a long, close look at the poverty, misery, and deprivation—and, inevitably, illness—in the sharecropper shacks and small-town black slums of the Deep South.” He recognized that he didn’t have to go to Africa to find poverty, as “there was a third world in the United States.”29 Geiger and several other physicians from MCHR, together with the Delta Ministry, a Mississippi civil rights organization, committed to staying in Mississippi once the Freedom Project had ended to continue providing health services for poor African Americans.30 Several nurses also came south for the Freedom Project and remained in Mississippi to provide health care services with MCHR and the Delta Ministry. One of these, Phyllis Cunningham, discovered that local people were often more comfortable interacting with a nurse than with a doctor. Cunningham provided pregnancy-prevention classes, helped organize for better sanitation facilities and regular garbage pick-up, and helped provide vaccinations.31
At a November 1964 meeting, after several months of experience in ad hoc health care provision among the poor black residents of the state, Jack Geiger, Count Gibson, and other MCHR and Delta Ministry physicians brainstormed about the best way to institutionalize better health services for poor African Americans in Mississippi.32 Geiger argued that a community health center modeled on the one he visited in South Africa in Pholela was the best way to make a long-term commitment to solving comprehensive health problems associated with poverty among African American Delta residents.33 He also argued that the health center should be controlled by the local blacks who would use it. Gibson, fellow activist and chair of Preventive Medicine at Tufts University Medical School, and John Hatch, professor and civil rights volunteer in Mississippi, decided to partner with Geiger. Gibson offered Tufts Medical School as a sponsor for the project and proffered Geiger a full professorship at Tufts so he could oversee the health center project. Hatch was the only African American of the three. He was born in Kentucky and, as he explained in an interview, had grown up in Arkansas on “the banks of the Mississippi River” and often earned money “working in the fields picking cotton.”34 Hatch trained as a social worker at Atlanta University and joined the faculty as an assistant professor of preventive medicine at Tufts Medical School.35
Geiger, Gibson, and Hatch approached the Office of Economic Opportunity (OEO) at the end of 1964 with their idea to implement one Neighborhood Health Center each in an urban and in a rural location, both of which would be administered by the Tufts Medical School. The first grant from OEO—funded with Community Action Program (CAP) dollars—paid for the two comprehensive centers. The Tufts professors, the Delta Ministry, and the handful of doctors and nurses from MCHR still in Mississippi after the Freedom Project ended benefited from growing support for health care reform within Johnson’s War on Poverty agencies.36
Important contextual factors made the mid-1960s a good time to promote radical health reform. For example, Johnson’s landslide victory in 1964 provided the final momentum needed to amend the Social Security Act to support health insurance for those over the age of sixty-five in the form of Medicare and health benefits for families on public assistance with Medicaid. The Watts riots, which occurred in August of 1965, also bolstered arguments that community failure along with poverty contributed to urban violence and ill health in large cities. Many pundits and policy makers began to call for community solutions to poverty and the social ills that accompanied it.37
Due to these gathering pressures to improve health care for the poor, the OEO developed the NHC program presented to them by Geiger and the others at Tufts. The details of the program emerged from negotiations for funding. The first two health centers were planned for Columbia Point, a housing project in Boston, which provided living space for six thousand people in twenty-six high-rise buildings, and in Mound Bayou, Mississippi, a small African American town in Bolivar County, which covered a 500-square-mile rural area. Applications to the OEO for health centers in the South Bronx, Los Angeles, Chicago, and Denver quickly followed on the heels of the Tufts projects. OEO funded all of these health centers as demonstration projects in 1965.38
Quickly, the NHC program funded comprehensive health service grants across the country with significant congressional support fostered by Senator Edward Kennedy of Massachusetts, who had been impressed by the demonstration project at Columbia Point. Amendments to Economic Opportunity Act legislation authorized in 1966 and 1967 established the OEO Comprehensive Health Services Program to fund a national network of more than 150 health centers. Between 1965 and 1971, OEO spent $308 million and the Department of Health, Education, and Welfare (HEW) spent $110 million on the health center program, which served nearly one million people.39 The Economic Opportunity Act legislation from 1966 stipulated that the program should make health services “readily accessible to low-income residents . . . furnished in a manner most responsive to their needs and with their participation and wherever possible . . . combined with, or included within, arrangements for providing employment, education, social, or other assistance needed by the families and individuals served.” By 1971, three-quarters of the centers were in urban areas, filling a gaping hole in urban health care as medical practitioners followed the wealth to the suburbs. Rural centers included a project on an Indian reservation in Minnesota and others near migratory labor camps in California.40
The health centers served the poor for free and the “near poor” on a sliding scale, with about one-half of the employees of the centers coming from the patient population.41 Although Geiger and others initially conceived of the NHC as free health care institutions designed to provide no-cost services to everyone within a community regardless of income, a 1967 congressional amendment to the Economic Opportunity Act linked NHC full-pay eligibility standards to Medicaid eligibility standards. Patients with incomes above the Medicaid standard could use the NHCs on a sliding scale.42 One economist who studied the NHCs argued that the most successful programs offered health services to everyone within a geographic area in which the vast majority of residents qualified for free medical care. In those cases there was little stigma for using the program.43
Planners of the NHC programs also intended to provide continuity of health services for poor patients accustomed to fragmented emergency room or outpatient public health department care. As one evaluator of the NHC program explained, NHCs responded to “fragmented care that was the only care available to many poor persons” in the form of “chest x-rays, immunizations, VD control . . . the fragments in the outpatient departments with their multiple specialty clinics, the fragments of provider continuity, the fragments with regard to the availability of services at selected times during the day or week, fragments with regard to the family, i.e., clinics that served only children, adults, [or] women” as was provided by most health departments and hospitals nationwide. Rather, the NHCs promised “comprehensive care in the concept of the neighborhood health center . . . implemented by providing single-system access to a full array of primary health care for families.” Most health centers housed a
