The last – and inexpressibly inspiring – session of our winter term course on community health centers was a couple days ago. It just happened to coincide with my reading of Atul Gawande’s latest New Yorker piece, which interestingly linked in with a lot of what I have been mulling over as a result of this community health center course.
But let me start at the beginning.
The community health center movement started about 45 years ago, with roots in the civil rights and social justice movements of the 1960s, and with some incredible leaders at the helm. At the dawn of this movement, community health center leaders saw health as but an entry point to solving a broader range of problems, without raising the same level of opposition as more blatantly political “social change” programs. The goal was to not just to provide primary care and related outreach and patient education, but to address social determinants of health through job development, nutrition, sanitation, and social services. All while maintaining a core principle of respect for and involvement of community residents.
While this belief in community ownership has persisted through the years, the idea of health as but an entry point to solving a broader range of problems seems to have diminished (though, thankfully, not disappeared). Most of community health centers have become primarily – some almost entirely –deliverers of medical care, with little attention paid to the broader – and more fundamental, in many ways – needs of these communities: education, employment, food access, civic engagement, health promotion/prevention (e.g. promotion of healthy eating and exercise, injury and violence prevention, etc.).
This is not to say that they are not doing absolutely amazing work – because they are. That, if nothing else, has become clear over the course of this class. Health centers provide needed high-quality primary care services to largely underserved populations (the under- and un-insured and the homeless, among others), preventing further complications and emergency room visits, while maintaining community engagement (aided by the legal requirement that governing boards of community health centers must be composed of at least 51% consumers) and a range of enabling services (such as provision of translation and transportation services).
So, needless to say, all our visits to community health centers over the course of the last two weeks have brought us into contact with awe-inspiring, committed leaders – most of whom have worked in their respective centers for upwards of 20 and 30 years. Pretty amazing to someone like me, from a generation that changes jobs every few years – to be passionate enough and challenged enough by a place to remain there for decades and still speak about it with such fervor would be one of the greatest blessings in life! While all our visits have been wonderful, our visit yesterday to the Codman Square Health Center was inspiring on an entirely different level.
Bill Walczak, the founder of the Codman Square Health Center, is, among a million other things, an incredible storyteller. A son of two factory workers, his seventh grade teacher changed his life, pushing him to apply to a high school that resulted in an excellent education and a full ride to Boston University. Within a year, he was a married, college dropout, working in a factory and organizing for Caeser Chavez’s lettuce boycott. He was also a resident of Codman Square in Dorchester, Massachusetts, a community that was falling apart at the seams. Buildings were abandoned as people fled from the racial tensions, escalating violence and crime, and crumbling education system. Labeled a “death zone” due to high infant mortality, and suffering house fires on a daily basis as people attempted to at least collect insurance money off of abandoned properties that no one wanted, the community suffered from a deep sense of hopelessness.
In 1974, a civic association in Codman Square decided to take over the basement of an abandoned library building and set up a health center, injecting some hope and excitement into this community. 20-year old Bill Walczak was chosen as chairman, because, he says, “I had a big mouth and it was a convenient way to shut me up”. (A statement that embodies his humility and sense of humor, I think). Since then, through immense hard work and tons of learning along the way (about politics, media, fundraising, healthcare regulations, building partnerships, etc. etc. etc.), the Codman Square Health Center has grown to occupy five buildings (all formerly abandoned), employ 280 people, and see over 100,000 people for services each year, including 20,000 patients, 87% of whom live below 200% of the Federal Poverty Level.
Moreover, it has stayed true to the original essence of the community health center movement – health as but an entry point to providing a much broader range of services that tackle the fundamental determinants of health, happiness, and success. The Center provides a range of public health and community services: adult education (e.g., computer classes), financial help (e.g., tax preparation, credit coaching, and personal finance classes, including a “skills for life” course for 11th and 12th grade adolescents that combines lessons in personal finance with career exploration), recreation and fitness opportunities (including a full-fledged fitness center through a partnership with HealthWorks), hands-on nutrition programs and cooking classes, parent and other support groups, youth services (including internships at the community health center), and civic engagement initiatives.
Most interestingly, inspired by the way education changed his own life, Bill Walczak, through immense initial opposition, has founded and closely tied into the Health Center a charter school, Codman Square Academy. With extended class time (9-5pm every weekday and half-days on Saturdays) and truly innovative programs in fitness, nutrition, social justice, and more, the small school (enrollment: 140, average class size: 17) serves largely low-income, minority students (99% students of color) and has seen some pretty amazing results over the course of its first ten years (100% of students accepted to four-year colleges and universities, and 73% of alumni graduated or enrolled in higher education). A full-time staff member is devoted to following students after graduation and aiding them in any way possible. It’s clear that students and faculty alike view the school as a second home.
Which brings me back to my earlier point – there are so many services that need to be integrated in order for communities to thrive. The day before our Codman Square visit, we visited Boston Health Care for the Homeless (which incidentally marked the third time I’ve heard its founder, Jim O’Connell, give his spiel – and I find myself just as moved and motivated every time), and when asked about the prevention of homelessness, Dr. O’Connell’s response was that homelessness is a prism that reflects the failures of society. Failures in education, prison/corrections, foster care, health care, welfare, housing – the list goes on.
An extremely eloquent turn of the phrase that again drives home the point that we are not going to solve a community’s problems just by providing medical care. We’re not even going to solve a community’s medical problems just by providing medical care.
This is an idea that Atul Gawande’s article touched upon. Specifically, Gawande talks about proper care for “hot spotters”, the small percentage of people who make up the vast majority of health care costs. He cites a number of great examples, prime among them a group in Camden, New Jersey, who are providing highly intense primary care, as well as a broader range of services, to these high-need patients. By building relationships, attempting to address the causes behind their medical problems and not just the symptoms, and connecting patients with social services, this small group of folks – many of whom have no academic background in medicine, but rather the skills to gain a patient’s trust and confidence – is making a huge difference.
So, ultimately, it’s about finding a way to tackle all these different issues in an integrated and community-driven way. I think community health centers, given their roots in their communities and their historical efforts towards broad ranging social change, provide a uniquely apt home-base from which to mount such a comprehensive, holistic effort. And I think Bill Wolzcazk and Codman Square provide an amazing example of just how much can be done on this front.
It is certainly a daunting thought – tackling education and healthcare, lifestyles and environments, policy change and entrenched interests. And all at once. But as Bill Walczak concludes his reflections on a healthy city (our final reading for the course) –
“We need to create integrated systems that promote community and health values. Like all change such cultural shift will take a generation or more to accomplish. But I am reminded of the story President John F. Kennedy told of the French leader who asked his gardener to plant a rare tree on his estate. ‘But the tree won’t bloom for 100 years’ the gardener said. The response: ‘In that case, plant it this afternoon.'”
So here’s to going beyond merely musing, and starting planting. Cheers.