Dr. Jack Geiger and colleague Dr. Count Gibson are often credited as the pioneers of the community health center movement in the United States. Dr. Geiger was active in the Civil Rights movement in the early 1940’s and, after completing his medical training, participated in the Freedom Summer in Mississippi in 1964. Within the following years, Dr. Geiger helped organize residents in Bolivar County, Mississippi, and in the Columbia Point Public Housing Project in Boston, MA, to establish the nation’s first two community health centers. The health centers were funded through the Office of Economic Opportunity, the agency directing the so-called War on Poverty. The early health centers provided important medical services but also addressed the social determinants of health such as poverty, unemployment, malnutrition, and environmental health issues. There are now over 1,200 health centers nationwide, which were modeled after these community health centers.
Career in Profile
- 1941-1943 – Studied Liberal Arts at the University of Wisconsin
- 1943-1946 – Military service
- 1947-1950 – University of Chicago, Division of Biological Sciences
- 1950-1954 – Science and Medicine Editor, International News Service
- 1954-1958 – Completed MD, Western Reserve University School of Medicine
- 1958-1959 – Intern, Harvard Medical Service, Boston City Hospital
- 1959-1960 – Completed MSc in Epidemiology, Harvard School of Public Health
- 1959-1961 – Postdoctoral Research Fellow, Social Science in Medicine, Harvard University
- 1961-1962 – Instructor in Preventive Medicine, Harvard Medical School
- 1962-1963 – Assistant Medical Resident, Harvard Medical Service, Boston City Hospital;
- 1963 – 1964 – Senior Resident in Medicine, Harvard Medical Service, Boston City Hospital and Research Fellow, Thorndike and Channing Laboratories
- 1964-1965 – Clinical Assistant, Harvard Medical Service, Boston City Hospital; Assistant Professor of Public Health, Harvard School of Public Health
- 1965-1966 – Associate Professor of Preventive Medicine, Tufts University
- 1965-1971 – Project Director, Tufts Comprehensive community Action Program; Director, Division of Community Health, Tufts University School of Medicine
- 1966-1969 – Professor of Preventive Medicine; Director, Division of Community Health, Department of Preventive Medicine, Tufts University School of Medicine
- 1969-1971 – Professor and Chair, Department of Community Health and Social Medicine, Tufts University School of Medicine, and Chairman, Ambulatory Care, Tufts-New England Medical Center
- 1971-1978 – Professor and Chair, Department of Community Medicine, State University of New York at Stonybrook, School of Medicine
- 1978-1997 – Professor and Chair, Department of Community Health and Social Medicine, City University of New York Medical School
- 1983-1984 – Senior Fellow, Center for Advanced Study in the Behavioral Sciences, Stanford University
- 2004-2007 – Visiting Professor of Epidemiology, Mailman-Columbia School of Public Health
- NOW: Arthur C. Logan Professor of Community Medicine, Emeritus, City University of New York Medical School
What led you to get involved with the creation of the community health center movement in the United States?
We all stand on the shoulders of others. The contemporary community health center, and the development of community-oriented primary care, was really developed in – of all places – apartheid South Africa in the mid-1940’s by Sidney and Emily Kark and their colleague physicians and others. There were more than 70 community health centers in South Africa serving Africans, Indians, and some poor whites.
In 1957, at the beginning of my senior year in medical school, the Rockefeller Foundation – which had heavily funded the Kark’s work along with the South African government at the time – gave me a scholarship to go for four months to study and work at the Pholela Health Center and an urban Zulu housing project health center called Lamontville in Durban. That experience changed my life. It taught me about community health centers and set me on the path to get what I thought was the appropriate training for global health, particularly in the third world.
I had been in civil rights work since I was a teenager starting in 1942. In 1964, at the end of my training, I went to Mississippi as part of the Freedom Summer with an organization that about twenty of us from across the country had started called the Medical Committee for Human Rights. It was created to be the medical arm of Freedom Summer and the Civil Rights Movement at its peak. That month in Mississippi, I had the chance to take a long look around and realized that I didn’t need to go to Africa, Latin America or Southeast Asia. All those problems existed here in the rural South, the urban northern ghettos, in Appalachia, in the Native American Reservations – not at the same absolute level but certainly at an unacceptable and hideous level, relative to the health of the rest of the population. With my colleague, Count Gibson, who was then chair of Preventive Medicine at Tufts Medical School in Boston, we kept coming back to Mississippi.
At a meeting in December of 1964 with many folks from the Freedom Summer and Indigenous Civil Rights Workers, sponsored by the Delta Ministry of the National Council of Churches, I said what really needed to happen in this country was the development of community health centers that would serve identifiable populations in need. I’d remembered my four-month time at Pholela and Lamontville, and thought we should bring that model here. We would use the principles of community-oriented primary care and population health to deliver services and, although we didn’t use the words at the time, address the social determinants of health.
There was a brand new federal agency – the Office of Economic Opportunity, the so-called War on Poverty – and that gave us our window of opportunity to first convince them to do this, and to make it a part of their community action program and to develop this new model of delivery of healthcare services. In January of 1965, I made my first approach to the people at OEO. After a lot of struggle and convincing, the first grant for the first two community health centers in this country – in rural Bolivar County, MS, and Columbia Point, a public housing project at the edge of Boston – was approved.
How hard was it to launch the first two health centers in the United States?
Columbia Point Health Center in Boston was relatively easy to open. Mississippi took a lot longer. It took a while to identify the site, and then to convince the Poverty Program, which was very nervous about working in place like Mississippi. We also had to deal with concerted opposition by the state Governor, the state public health department, and the state medical society, and all of the other forces aligned.
Despite the fact that their own data showed an overwhelming need – huge, third world level infant morality rates in the African-American population – they recognized that this was a very different model and it would directly empower impoverished black populations as partners in the delivery of their own health services, thus bypassing all the gatekeepers and mechanisms of control that the white power structure had up until then exercised.
How did the new model of care directly empower the populations you were serving?
From the very beginning, one of the most important components of the health center effort – along with the doctors, nurses, public health nurses, and sanitarians and environmental engineers and social workers, and the all other kinds of people that we had managed to recruit and assemble – was what we called community health action, which was really community organizing. We did careful and prolonged and solid community organization – rather than just picking existing community leaders who tended to step forward and say “Looking for the community? Here we are.” – and organized ten different community health associations in the ten major areas of our 500 square mile piece of Bolivar County. That took time, explanation, and innumerable meetings for people to begin to understand what we proposed to do, and to assess their own health care needs.
What were the most successful interventions at Mound Bayou/Columbia Point?
Simply to deliver medical care but also hospital care in two small black hospitals that existed in Mound Bayou, the town where we were physically based, but with satellite centers at ten different points throughout our target area – to people who had never before seen a physician under the old plantation system. The cotton sharecropper system had collapsed and been replaced by mechanization, and there was profound poverty and profound unemployment. There was widespread hunger. There was widespread unemployment. People were squatting on the land in old plantation shacks and they had no significant prior access to medical care, except for the work of some fraternal organizations that had built those two small hospitals and in effect sold health insurance for 25 cents or 50 cents a week.
To deliver medical care to populations living in those circumstances would have been simply to send people back from the health center into environments that determined overwhelmingly that they would be sick and hungry and burdened with the same illnesses all over again. They were drinking water from the drainage ditch or collecting water in old pesticide drums. They were often living in housing that wasn’t fit for human habitation.
So I would say that our second most important intervention was a series of environmental interventions. We dug protective wells. We built sanitary privies. We thought we would start vegetable gardens as a way to start to combat hunger, and hopefully we would get maybe 100 families to do that. We were sitting on some of the richest topsoil in the United States. A thousand families raised their hands. What emerged from that, as a partner to the health center, was a 500-acre, triple crop, irrigated vegetable farm that grew thousands of tons of greens, potatoes, sweet potatoes, lima beans, peas, kale – you name it – over the next several years. Those thousand families and members traded their labor for shares in the crop – nutritional sharecropping. But this was a different kind of plantation because with both foundation and governmental help, the Farm Co-op was, as the name indicates, a cooperative. The people who worked the land owned it. We virtually eliminated malnutrition in our target area.
Is there a success that you are most proud of?
There are now more than 1,200 community health centers in the United States delivering care at 9,000 different points of service around the country and taking care of something like 22 million people. And of course that’s not me, that is thousands and thousands of people working in those community health centers and their supporters. The community health center has become the backbone of the healthcare safety net in this country. That’s something that I don’t think we even dreamed of when we were starting those first two health centers.
How far do you think we’ve come, as both a nation and the community health center movement specifically, in addressing social determinants of health?
In the first years of the health centers, it wasn’t rocket science to figure out that medical care alone was insufficient. But national political administrations changed and there were efforts by both the Nixon administration and later, in particular, by the Reagan administration, to block grants to health centers, to hand them back to the states, including the southern states, to remove the direct pathways to community empowerment. While those efforts were beaten back, often by Republican congresses in the face of those presidential efforts, community health centers, starting in 1975 and to some extent ever since, have been increasingly restricted to simply the delivery of personal medical services – primary, preventative and curative care – rather than other kinds of interventions. Although, I should add that many health centers found state, local, philanthropic or other funding sources to undertake efforts to continue doing such additional things themselves.
What has happened now, and that is beginning to happen, is that community health centers and indeed hospitals and other health delivery organizations, are going to have to do this by collaborative efforts with other organizations – with public health agencies, with housing departments, with transportation departments, with county executives – to mount, in collaboration, the same kind of interventions.
What is the most persistent public health problem today and what is your ideal solution?
That one is easy. One word: Poverty. That comes before any specific disease identification, HIV, Malaria, malnutrition, you name it. Because they all are linked to poverty, attended by poverty, spread from centers of poverty. One of the things that is very poorly appreciated is that when the War on Poverty, and the whole series of efforts that it represented – the health programs, the Job Corps programs, Head Start – all of the other things that the Poverty Program did in the 1960’s and 1970’s, when the Poverty Program began, the poverty level in this country was roughly 22%. That’s when Michael Harrington wrote “The Other America” and put this on our national agenda. Twenty-two percent of the population of the United States – a fifth – was in poverty. Ten years later, that proportion was 11%. That is a phenomenal success and should be a guideline for the fact that we need to continue that kind of effort and re-launch it now.
This feature was interviewed, transcribed and partially edited by our guest editor, Ted Henson.