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For Health and Freedom

Civil rights activists knew their struggle was incomplete without winning a just health care system. They're an inspiration for single-payer activists today.

Members of the Medical Committee for Civil Rights at the 1963 March on Washington. National Library of Medicine

When we tell the story of the American civil rights era, we often leave out a crucial element: the movement for social medicine and community health. Funded by Lyndon B. Johnson’s War on Poverty and influenced by innovations in social medicine in South Africa, this new health care movement recognized that good health played an integral role in social equality.

In 1964, a group of New York doctors organized the Medical Committee for Human Rights (MCHR) to provide first aid to activists in Mississippi during Freedom Summer. Historian John Dittmer writes about the MCHR and its precursor, the Medical Committee for Civil Rights (MCCR), in The Good Doctors: The Medical Committee for Human Rights and the Struggle for Social Justice in Health Care.

That same year, the Economic Opportunity Act (EOA) provided almost a billion dollars for federal programs aimed at helping the poor. H. Jack Geiger, who participated in the MCHR, managed to direct some of that money to Mound Bayou, Mississippi, a rural community with staggering unemployment, little access to education, and crumbling medical facilities. Thomas J. Ward Jr’s new book, Out in the Rural: A Mississippi Health Center and Its War on Poverty, documents the legacy Geiger and his comrades left in this tiny Mississippi town.

Taken together, The Good Doctors and Out in the Rural give contemporary activists a model for reforming our broken health care system. As the movement for “Medicare for All” gains momentum in individual states and in Congress, the Left should take inspiration from these activists, who saw that the work of the Civil Rights Movement was not complete without winning access to just and universal health care.

The Freedom Summer's Doctors

The MCCR had a short life, but the role it played in developing new health care practices in the United States outweighs its brevity. Physician-activist Walter Lear organized the group in the spring of 1963 to end racial discrimination in the medical profession. When its members protested the American Medical Association’s racially discriminatory practices that June, Robert “Bob” Smith, from Jackson, Mississippi, was the only black doctor to walk the picket line.

Meanwhile, the Student Non-Violent Coordinating Committee (SNCC) was planning its Freedom Summer. It chose Mississippi, where in 1960 less than 2 percent of the state’s black population was registered to vote, the product of a long history of voter suppression, intimidation and organized violence. If they could get out the black vote in Mississippi they could do it anywhere.

In 1954, just two months after the landmark Brown v. Board of Education decision, white supremacists in Indianola, Mississippi formed the White Citizens’ Council; its most prominent member, plantation owner James O. Eastland, also chaired the US Senate’s judiciary committee. The WCC received financial support from the state legislature to track and terrorize any Mississippians who supported black voter registration or integration.

In some areas black residents still lived under curfew. High-profile killings, beginning with Emmett Till in 1955, brought national attention to the region, but many more anonymous victims also died at the hands of white supremacists. Mississippi — especially the Delta — was about as hardcore as it got.

The plan for Freedom Summer was to register as many black residents as possible. SNCC would bus in an army of middle-class, mostly white student volunteers to help staff the project, which would culminate when the Mississippi Freedom Democratic Party challenged Mississippi’s all-white delegation at the Democratic National Convention that August.

The Kennedy administration, reliant on Dixiecrat support, had largely allowed white racists to murder black civil rights workers with impunity. SNCC knew that television cameras would follow the white students, forcing the federal government to enforce the law.

When Bob Smith heard that a thousand students were coming to Mississippi, he foresaw a deepening of the ongoing health care crisis in his state. Only fifty black physicians worked in Mississippi in 1964, and many, fearing repercussions, refused to treat civil rights workers. Smith knew the project needed outsiders to treat the “outside agitators” (and the inside ones, too).

He contacted Tom Levin, a psychologist he’d met on the picket line the previous summer, and asked him to round up doctors to go to Mississippi. Dittmer writes that Levin, barely able to contain his enthusiasm, envisioned the doctors as the “Abraham Lincoln Brigade of the civil rights movement.”

Geiger was one of the more than one hundred health care professionals who went to Mississippi to support Freedom Summer. All were left-wingers who had worked with the Physicians Forum, organized in 1941 to advance the (still) radical notion that health care is a human right. Most had also worked with Lear’s MCCR before it folded.

If Bob Smith connected the civil rights movement in Mississippi and Old Left physician-activists from the northeast, Jack Geiger built a bridge between that movement and a remarkable experiment in social and community medicine that began in South Africa in 1940.

Community-Oriented Health Care

While still in medical school in 1957, Geiger went to South Africa for a clinical clerkship with Sidney and Emily Kark. They had built a health center in Pholela, located in the mostly remote region of what is now KwaZulu-Natal, part of the 13 percent of the country the government set aside for the Africans evicted from their homeland. There, Geiger learned the principles of what would come to be called community-oriented primary care (COPC), which blends clinical practice with environmental health, prevention, and epidemiology.

During World War II, the Karks had joined a small cadre of progressive physicians, public health innovators, and government officials committed to delivering health care to black South Africans, many of whom had never seen a Western-trained doctor before.

In Promoting Community Health: From Pholela to Jerusalem, the Karks describe their enumeration system, which began with defining a community’s geographical area, recruiting health workers from that community, and training them to conduct field surveys of water supplies, environmental hygiene, and nutrition.

Health workers helped residents make vegetable gardens and build privies. They collected household census data that comprised the denominator of the enumeration system. Epidemiologists extracted numerator data from clinical files of those who visited the center and records from school physicals.

This was where the analytical work — a central feature of the Karkian project — began. The team constantly monitored and evaluated the data as it came in. Social scientists poured over field surveys and vital statistics — live births, stillbirths, infant and maternal mortality, and specific illness rates — to identify changes and estimate probable causes of disease.

Mervyn Susser, who did a clinical clerkship with the Karks in 1949, recalled the health center’s walls “plastered with charts” that illustrated “over weeks and months, graphs of sentinel health events and trends.” By merging epidemiology with clinical practice, health teams could anticipate epidemics and devise early interventions. This new health care practice represented a shift away from traditional approaches that emphasize individual health. In the Karks’ model, doctors planned for the individual’s health as well as that of her family and community.

In 1944, Dr Henry Gluckman headed a parliamentary commission that pressed for a complete reorganization of South African health care using what he had observed at Pholela. Its recommendations placed South Africa at the forefront of health care in the postwar era. It even anticipated the World Health Organization’s mission statement, which declares that health is “not only absence of disease but a maximum degree of physiological and mental efficiency.”

This new understanding of health care required new ways of training doctors. A year after the Gluckman Commission, Sidney Kark’s Institute for Family and Community Health at the University of Natal Medical School — the only postsecondary institution for non-white South Africans — started training practitioners, community health workers, and social scientists to work in multidisciplinary teams at the health centers and conduct research in social medicine.

When Geiger arrived in South Africa, the racist Afrikaner National Party had been in power for nine years. Between 1945 and 1952, approximately forty-four health centers set up operations, barely 10 percent of what Gluckman had recommended. Most were in dilapidated buildings. The government also passed the Separate University Act, which would dismantle the IFCH.

In a letter to an American funder, Kark wrote that he and his associates at Natal felt the “sword of Damocles” hanging over their heads. While teaching Geiger the principles of social medicine and COPC, Kark knew that his work would continue in the future — but it would have to be in another place.

Beyond the Doctor's Office

The future of COPC began in Mississippi seven years later.

In August 1964, while the Democratic Party was refusing to seat the Mississippi Freedom Democratic Party at its convention, Lyndon Johnson pushed the Economic Opportunity Act (EOA) through a Congress keen to memorialize the recently assassinated John F. Kennedy. The bill committed $947 million for an array of programs, ranging from job training to legal services, that the federal government would directly administer, bypassing local governments.

Predictably, debate over the bill centered on states’ rights. Also predictably, the final version included amendments that allowed governors to veto federal funding for any project they disliked.

Even though health care did not appear in the original EOA, securing federal funding to create a health center in the Mississippi Delta was relatively easy. In Community Health Centers: A Movement and the People Who Made it Happen, Bonnie Lefkowitz calls the Office of Economic Opportunity, which implemented the War on Poverty, an “antibureaucracy.” Unlike career civil servants, many OEO staffers held temporary positions. They worked quickly, developing new concepts, nurturing projects, and meeting with nontraditional experts, including activists.

Geiger knew Mississippi would never approve federal funding for a health care program targeting poor African Americans. But he saw a loophole. The EOA included grants to institutions of higher education that no southern congressperson had thought to make subject to veto. Geiger exploited this, working with his old MCHR comrade Count Gibson, who chaired the Department of Preventive Medicine at Tufts University Medical School.

Nothing in the law said the OEO couldn’t give a grant to a university in Massachusetts to support a project in Mississippi. Geiger and Gibson imagined the only objection to this scheme would come from Massachusetts, whose governor might not want a university in his state to funnel money to Mississippi when poor people at home needed health care. So their proposal included one health center at the Columbia Point Housing Project in South Boston and the other in what turned out to be Mound Bayou, Mississippi. When I talked to Geiger in 2011, his eyes danced when he said, “We reinvented carpet-bagging.”

Located deep in the Delta, Mound Bayou was founded in 1887 by Isaiah T. Montgomery, formerly enslaved by Joseph E. Davis, the brother of Confederate president Jefferson Davis. Ward writes that, at the turn of the twentieth century, Mound Bayou “stood as a beacon of black success in the midst of Jim Crow oppression.”

In 1942, the Knights and Daughters of Tabor had opened the Taborian Hospital. A schism in the fraternal order would lead to two smaller hospitals, both funded by membership dues. Sharecroppers and tenant farmers, producing cotton in the Delta’s rich alluvial soil, kept the hospitals open.

This system wasn’t sustainable. In the 1950s, competition from synthetic fabric coupled with mechanized cotton harvesters, each capable of doing the work of forty or more people, displaced agricultural workers. Planters now needed barely a fifth of their former workforce. Unemployment ran high. When Geiger arrived in 1965, membership had dropped, and both hospitals had deteriorated. If not for Mississippi’s lenient hospital regulations and racial segregation, they would have closed.

Geiger knew that the optics of a northern Jew who arrived with funding from the federal government and a private university in Boston to create a health center in a black town in the Delta was problematic. Even before the project began, he convinced the OEO to fund hospital care on the condition that the two failing hospitals merge into the Mound Bayou Community Hospital.

After the merger, the fraternal orders resisted appointing a new board that include representatives from the rural poor: the OEO required “maximum feasible participation of the residents of the areas and groups served.” Eventually, the fraternal orders agreed to appoint only one-third of the board of directors, and the rest came from the target population.

Mound Bayou’s ruling class, deeply resentful of Geiger and the OEO, would be a thorn in the side of the health center for years, often siding with Mississippi’s segregationist governor and other white elected leaders, including Senator Eastland.

The social medicine that Geiger pioneered at the Tufts-Delta Health Center (TDHC) derived from what he had learned in South Africa but was also profoundly shaped by the residents’ needs. The center served fourteen thousand people living on five hundred square miles in northern Bolivar County. Median family income sat at just $900 a year. Most residents were functionally illiterate, having attended, on average, four years of school. Many had never seen a physician before. Prenatal care was nonexistent, and the high infant mortality rate — 54.4 deaths per thousand, more than twice that for white infants and 4 percent higher than the national black infant mortality rate — reflected that.

Geiger saw the TDHC as more than a health center. He believed it could become an instrument for community development and social change. He recruited John Hatch, a black community organizer, to get local residents involved in setting health priorities for themselves and their communities.

In the year before the TDHC opened, Hatch traveled through the tiny hamlets in north Bolivar County soliciting input and helping residents organize ten health associations. These semiautonomous organizations eventually led to the creation of the North Bolivar County Health Council, which coordinated activities and acted as the TDHC’s advisory body. Thanks to this community participation, the health center became less concerned with statistics and more committed to improving the social determinants of health: what makes people sick in the first place.

Hatch learned that Delta residents were not interested in health care, at least not in the traditional sense. They recognized, perhaps in different terms, that environmental health posed the greatest threat to them. A population cannot be healthy without healthy places to live. Open sewage ran through front yards, and children drank water out of drainage ditches.

TDHC’s sanitarian Andrew James found “sewered white areas and non-sewered black areas,” revealing that black Delta residents subsidized services for white residents that the former never received.

The health center’s legal department worked with ACLU and NAACP attorneys, who partnered with local residents already working to bring sanitary facilities into their communities. Hawkins v. Shaw [Miss] (1971) set a precedent for other southern cities, holding that the Fourteenth Amendment’s equal protection clause requires that municipalities equalize public services. Ward writes that the legal and political fights that led to Shaw were an “extension of the civil rights movement, but for clean water and sanitary communities instead of access to public facilities and the ballot.”

When Hatch visited communities to discuss the health center, he most often heard about hunger. “Health services are fine,” said one attendee at an organizational meeting, “but for the love of God, can you share some food?”

The TDHC came up with an ingenious short-term solution: physicians would write prescriptions that could be redeemed at local grocery stores and reimbursed by the TDHC. The governor of Mississippi tried unsuccessfully to stop it. Geiger recalled using the mantra that Sidney Kark taught him years earlier — anything a physician can do to improve a patient’s environment is considered fair therapy — to convince the feds to let the health center use its pharmacy budget for food.

They also created a long-term solution: the North Bolivar Farm Co-operative. If area residents were lukewarm about traditional health interventions, they were wildly enthusiastic about growing vegetables. Eventually, the co-op, owned and operated by area residents, cultivated hundreds of acres of land and ran a wide distribution program. Hatch contracted with a facility nearby to flash freeze vegetables and store them in a food locker for year-round consumption. They also used the food locker to store meat purchased at wholesale prices or from local black farmers and sold to members at cost.

The co-op slowly expanded its operation to sell used clothing, operate a sandwich shop at the health center, and open an African-American book and record shop in Mound Bayou. Unfortunately, the project never became entirely self-sufficient; when funding contracted under Nixon, Alcorn State University took over the co-op and now runs it as a research farm.

Natal in the Bronx

Soon after Geiger and Hatch reinvented health care in Mound Bayou, a brilliant young doctor named Harold Wise secured OEO money to create a neighborhood health center in an impoverished and medically underserved area of the South Bronx.

With support from the Division of Social Medicine at Montefiore Hospital, Wise’s Bathgate Avenue Health Center (rechristened the Martin Luther King, Jr Health Center in 1968) was part of the OEO’s second generation of community health centers. Wise’s project, influenced by Geiger’s work, was also distinctive, a result of the South Bronx’s unique demographics (Puerto Rican and African American) and social conditions.

Like his predecessors, Wise recognized that health is predicated on financial security, habitable living, and a healthy environment. He realized early on that providing a defined population geographic access to clinical health care was the easy part; more difficult was what he called “social accessibility.” To bridge this gap, he created a new health care para-profession: the Family Health Worker (FHW).

She — a woman by design — was recruited from the community and trained to perform a variety of functions, from home nursing to complex social casework: everything from forcing landlords to make building repairs to helping residents navigate public assistance.

Multidisciplinary health teams could not function without the FHW, and she became the critical link between the health center and its target population. She spoke the language of the residents and served as their advocate “against a variety of establishments, including the medical establishment.” She explained health care hierarchies in the barrio, which included both pharmacists and botanicas, and physicians were required to defer to her.

Health care, said Wise, sounding a bit like John Hatch, could not “originate [from] outside a community and then be served up . . . as a ‘fait accompli.’”

The Demise of COPC

Sadly, these innovations were short-lived. Nixon transferred the OEO to the Department of Health, Education and Welfare, where it began funding traditional clinical health services. In 1972, the department merged the TDHC and Mound Bayou Hospital. This time, the hospital got to choose its own board of directors, and it selected only members of the local elite.

The merger allowed Nixon to score points with two constituencies: those who demanded community control for African Americans and the white voters he’d won over to the Republican Party with his “Southern strategy.” Because the merger cut the health center’s academic affiliation, it closed the loophole that prevented governors’ vetoes.

In 2014 the Delta Health Center dedicated a new building on its campus: the Dr. H. Jack Geiger Medical Center. This well-deserved honor is not without cruel irony. The community-oriented primary care that Geiger introduced in Mississippi in the mid-1960s has long been forgotten. The medical center named for the great pioneer in public health and social medicine during the civil rights era now dispenses traditional medical care.

Today the MLK Center in the South Bronx and the Geiger Medical Center in the Delta are two of more than twelve hundred health centers scattered around the United States in rural and urban areas that provide traditional preventive and curative medical services to the poor. When the OEO began funding health care in 1965, federal restrictions limited services to the poor, assuring a two-tier health care system. A system created only for the poor can be more readily dismantled than one created for all Americans.

In 2012, when the Supreme Court’s ruling on Obamacare said that states were not required to expand Medicaid, many liberals regarded the decision as a victory because it also upheld the individual mandate: the cornerstone of our health care system that is organized around for-profit insurance companies.

This winter, Republican efforts to dismantle Obamacare drew crowds to town halls; many indignant attendees and protesters saw the next step as providing insurance for all, not reversing the Affordable Care Act’s limited gains. They recognize what the Karks, Geiger, and Wise knew: the only way to protect us all is to create a universal medical system, with no socioeconomic tiers.

Bernie Sanders calls this Medicare for All. I call it a step in the right direction.