If health care means the prevention of illness and not just caring for the sick, then health services should be integrated into the goal of creating healthy communities. Policy makers should examine how health services can be embedded in local communities and integrated with the goals of job creation, community development, and sustainability which are presently being pursued on separate tracks by the Clinton administration.
A community-based approach to health services is not a new concept. Many of the anti-poverty programs of the 1960s, funded through the Office for Economic Opportunity (OEO), took a holistic approach to the improvement of the lives of the poor. They frequently rested on the foundation of neighborhood or community health centers with a focus on maximum participation of the community.
One example is in Mound Bayou, Mississippi, where the Delta Health Center was founded in 1965.
The center began, not by the traditional means of building a structure and hiring a professional staff, but with a series of meetings in homes, churches and schools. As a result of these meetings, the residents of this very poor region created 10 local health associations, each with their own perspectives and priorities. Some needed clean drinking water without having to walk three miles, others needed child care or elder care. Community participation led the health professionals to broaden their conception of "health" to include food, jobs, housing and education, as well as personal and public health.
In the words of Dr. Jack Geiger, a founder of the center: "Once we had the health center going, we started stocking food in the center pharmacy and distributing food – like drugs – to the people. A variety of officials got very nervous and said, ‘You can’t do that.’ We said, ‘Why not?’ They said, ‘It’s a health center pharmacy, and it’s supposed to carry drugs for the treatment of disease.’ And we said, ‘The last time we looked in the book, the specific therapy for malnutrition was food.’ There was nothing in the regulations that said otherwise, so we continued to do it."
But this was only the beginning. Poor sharecroppers throughout the 500 square mile area, displaced by the double-row cotton picking machine, decided it was time to pool their labor and grow food instead of cotton. With additional OEO funding, they found land and established a food growing and distributing cooperative. In the first seven months, a million pounds of food was grown, ending hunger and producing some surplus. Housing programs were also begun, sewage systems were developed, and schooling was improved.
Funding has been cut back and federal regulations have confined staff to carrying out traditional medical care, but Delta Health Center continues to be a center of community life and a symbol of hope for people who are left out of the mainstream of the nation’s life.
Another community-based approach was developed in the 1970s and introduced in Congress by Representative Ron Dellums of California as the Health Service Act. Health services would be based on local health needs as determined by community health boards. While similar in concept to local boards of education, these boards would have an opportunity for broader input into community planning. Under a system that has been described as "community federalism," the members of the local boards would elect district and regional boards responsible for operating hospitals and training health care workers.
Today, another federal initiative designed for poor rural and urban areas provides a potential model that could be developed and used to move all communities toward community-defined health services.
The Budget Reconciliation Act of 1993 authorizes establishment of nine empowerment zones and 95 enterprise communities. The applicant process requires broad-based local input in developing a strategic vision for change that responds to community needs in a comprehensive fashion, creates jobs, and is sustainable.
Other federal programs for needy areas can be dovetailed. The Small Business Administration has a microloan program for small entrepreneurs who can’t get credit from banks, and HUD now helps fund the National Community Development Initiative, created by private foundations to provide low-interest loans to nonprofit community development organizations.
Public and private pension funds can also be invested to meet local community needs, following the example of New York City, where pension funds have been invested in housing.
Clearly, creative partnerships can be forged between federal programs and private and nonprofit funding in support of local community initiatives. By combining these initiatives with community health activities, the first steps toward meaningful local job creation and community-based preventive health care can be taken.
Ruth Caplan coordinates the Economics Working Group, a project which examines underlying economic issues related to environmentally sustainable development. She worked for seven years as executive director of Environmental Action, where she co-authored the book, Our Earth, Ourselves.
Leonard Rodberg teaches urban affairs and health policy at Queens College/CUNY in New York City. In the 1970s he led the development of the Dellums Health Service Act. More recently, he has been involved in the health care reform and sustainable development debates.