Today, there are 37 federally qualified community health centers throughout Massachusetts, a large number relative to the state’s population and geographic size. This is no accident, and reflects the long-standing history of health care activism in the state. Significantly, Massachusetts has the unique distinction of being the home of the first urban federally-funded community health center in the country, founded by Drs. Jack Geiger and Count Gibson in the Columbia Point housing development located on an isolated peninsula in Boston’s Dorchester neighborhood. On a recent visit to the state, I met with Ellen Hafer, the EVP and COO of Massachusetts League of Community Health Centers, to discuss the history of community health centers in Massachusetts.
While Boston is renowned for being home to three of the best teaching hospitals in the country, and to outsiders seemed an unlikely place for the birth of the first community health center, the city’s neighborhoods had strong, independent identities and were segregated by culture, race, and ethnicity. Significant pockets of poverty existed amidst these prestigious teaching hospitals. Residents in geographically isolated and racially divided sections of the city, in particular the South End, Roxbury, Dorchester, Jamaica Plain, and East Boston neighborhoods, lacked access to basic medical services.
Columbia Point was one of the poorest sections of Boston prior to the opening of the health center in 1965; residents of the Columbia Point Development housing projects had no access to health care services.
Drs. Jack Geiger and Count Gibson partnered with Tufts University Medical School to develop the concept and plan for the health center, and sought support from the federal Office of Economic Opportunity (OEO), the government entity charged with developing and implementing the War on Poverty programs that were created as part of President Lyndon Johnson’s Great Society initiative. The Johnson Administration advocated community participation to create jobs and training and to foster economic development. The War on Poverty aimed to reduce poverty by expanding the government's role in education and health care, and the OEO was created as a cornerstone of this strategy. Another significant element of the War on Poverty was the creation of the Model Cities program, which aimed to foster urban renewal in marginalized communities through the creation of affordable housing alternatives, workforce development, social service programs, job training, and community organizing. Citizen participation was emphasized as a key strategy in the effort to rebuild and rehabilitate blighted urban areas and form a social service infrastructure. Under the Model Cities initiatives, community activists began to rally poor residents to demand and plan for better social services and access to primary and preventative health care emerged as a key issue. In cooperation with city agencies and in response to pressure from local community leaders, Boston hospitals aligned themselves with their home neighborhoods and supported the formation of community clinics.
The opening of the Columbia Point Health Center initiated a grassroots movement in the city that led to the opening of 18 additional health centers in Boston by 1971. Major teaching hospitals took a larger role in community-based health issues and worked with local activists in the Jamaica Plain and Roxbury neighborhoods. The Harvard School of Public Health worked with residents of Bromley Heath housing project to open Martha May Eliot Health Center in Jamaica Plain and Boston University Hospital was involved in the initial formation of Roxbury Comprehensive Community Health Center. Like Columbia Point and the Delta Health Center, in Mound Bayou, Mississippi, also established by Dr. Geiger together with Dr. John Hatch as the nation’s first rural health center, these centers were funded through the Office of Economic Opportunity. Boston’s Health and Hospitals Commissioner further stimulated growth by pushing a city-wide “redistricting plan,” which offered financial incentives for local hospitals to develop community-based health centers and to provide primary care in certain Boston neighborhoods. This policy helped to decentralize access to health services and created a neighborhood-based health center model.
By the 1990s, the Columbia Point housing project had been converted into a mixed-income development and a majority of the apartments were converted to market-rate housing with a percentage of subsidized units remaining for lower-income residents. As the demographics of the neighborhood changed, Columbia Point Health Center experienced financial trouble, due in part to a declining patient base. In order to avoid closure, Columbia Point merged with nearby Neponset Health Center, which had historically served a largely Irish Catholic working-class population. This unlikely partnership was led by Dan Driscoll, CEO of Harbor Health Services, the parent organization of the merged and expanded health centers. Driscoll explained that the cooperation between these two centers and their community boards was motivated by a mutual commitment to the survival and growth of their respective centers and by a larger commitment to the mission of community health centers to create access to care for underserved populations. The original Columbia Point Health Center changed its name to the Geiger Gibson Community Health Center in honor of the founders of the community health center movement.
Over time, Boston experienced significant change with waves of immigration and the gentrification of formerly segregated communities. As Boston has been transformed by gentrification, housing prices have increased, and poor and lower-income people have been forced to settle farther outside of Boston proper. These Boston bedroom communities are also experiencing a transformation and health centers have identified a strong need for affordable health services in these areas. Driscoll explained that
Pockets of poverty exist in suburban communities where the needs are less visible than in dense and segregated urban communities. like Dorchester. The health centers have evolved to meet the changing needs of their communities. Because the population is spread across a larger area with a less centralized community, residents are more difficult to reach and have less access to comprehensive care services. Harbor Health Services took on this challenge with the opening of a health center in Hyannis and a dental clinic in Harwich in the early 2000s. They have plans to expand to a brand-new site in Plymouth in 2014. Meanwhile, the original centers have adapted to a new population. Neponset has seen an influx of Vietnamese immigrants, and the center has expanded onsite translation and interpreter services. In addition, the center’s social work staff has mentored a cadre of Vietnamese men and women to provide outreach in the community, identify particular health needs, and encourage Vietnamese patients to seek services at the health center.
Forty-five miles outside of Boston, in Worcester, Great Brook Valley Health Center, now known as the Edward M. Kennedy Community Health Center, opened in 1986 in one of the largest public housing developments in the city. The center was first founded in the early 1970s by a group of mothers who lived in the Great Brook Valley apartments along with several board members from UMass hospital who worked together to secure funding to open a clinic. Similar to the Columbia Point center, the housing project was geographically isolated from the rest of the city and had no public transportation. Current CEO Toni McGuire recalled the isolation residents experienced: “There was one road in and one road out of Great Brook.” In a city notorious for gang-related violence and crime, residents had difficulty accessing basic medical care and ambulances were too often slow to respond or refused to enter the valley.
Renamed in 2010 to honor the late Senator Edward M. Kennedy, the center has responded to local needs and over the years has evolved to serve the changing demographics of the community. Worcester has experienced an influx of immigration from Latin America, Southeast Asia, West and East Africa, and the Middle East and has become a settlement site for large numbers of Somali, Liberian, Iraqi, Irani, Burmese, and Bhutanese refugees.
These patients have changed the face of the health center, where translation services are provided in over 30 languages and more than 75% of health center staff is bilingual. (primarily in Spanish and Portuguese, which remain the most commonly spoken languages by patients). Health center staff receives onsite training to address the specific health disparities and cultural needs of these patients. A special task force focuses on outreach strategies and challenges in meeting the needs of these residents, many of whom are unfamiliar with the Western medical system. Today, the center provides primary and specialty care services including one of the first health-center run HIV/AIDS prevention and treatment programs and operates 13 sites that serve the communities of Worcester, Clinton, and Framingham, Massachusetts.
The East Boston Neighborhood Health Center opened its doors in 1970. East Boston was originally a series of islands off the coast of Boston proper that were connected into a single landmass with landfill. Separated by Boston Harbor, East Boston suffered from a lack of access to ambulatory and primary care in large part due to its geographic isolation from the nearby city. It has always been a city of immigrants. The Center’s windows face a large outdoor mural that paints a visual history of immigrants in East Boston beginning in the 19th century with Irish, Canadian, Italian, and Russian Jewish settlers who were attracted by a booming shipbuilding industry. Also depicted are the more recent waves of immigration from the Caribbean, Central and South America, and Southeast Asia. Because East Boston has always had a low crime rate and is relatively affordable, it has attracted a largely working class immigrant population who seek a home to raise their families.
East Boston Neighborhood Health Center (EBNHC) is one of the only centers with an ambulatory care unit that is open 24 hours, 7 days a week. Because the closest hospital is not easily accessible, the ambulatory care unit is a literal lifesaver for many patients in need of emergency treatment. The facility is equipped with top-of-the-line ER equipment including x-ray equipment, an onsite pharmacy, and laboratory. Medical staff is trained in acute care and have streamlined the intake process to ensure patient walk-ins are able to see a physician in far less time than a typical hospital emergency room visit.
Another unique program at EBNHC is the Education and Training Institute. With more than half of staff members residing in the communities they serve, the center has taken steps to increase this number and to further the education and training of current staff who seek to advance their health center careers. Manny Lopes, the current CEO, personifies the health center’s commitment to training and development. A native of East Boston and a first-generation American child of Cape Verdean immigrants, he began his career at EBNHC as an 18-year-old researcher and worked his way up to the leadership role he serves in today. Passionate about the growth of the center and with a deep connection to the community it serves, Lopes explained how EBNHC was an important economic engine and source of jobs in the community and has worked to foster ties with local businesses.
Reflecting on the progress that has been made since the founding of Columbia Point, Massachusetts League of Community Health Centers staff with ties to the early health center movement cited a genuine spirit of engagement and active community governance in Boston that made community health center growth uniquely successful. Boston’s neighborhoods, in collaboration with outside leaders like Dr. Jack Geiger and Dr. John Hatch, broadened the centers’ influence to expand and secure funding. The city government was integral to initiating these programs through OEO.
Today 1 out of every 2 Boston residents receives care at a community health center, and while a large number of Boston health centers are not federally funded, they follow traditional health center model tenets. Massachusetts has led the charge in reforming the health care system and expanding health access. The passage in 2006 of Massachusetts’ landmark health reform law, Chapter 58, which expanded eligibility for the state’s Medicaid program and created subsidized insurance coverage for low- to medium-income residents, was the culmination of a decades- long political struggle that began under Governor Michael Dukakis who first made universal health care an important part of his 1988 Presidential campaign.
The strength of Boston’s health center movement can be attributed to its unique formula: the initial and sustained support of local government officials who pushed local hospitals to support community health centers within Boston’s tight - knit neighborhoods, the creative vision of leaders like Drs. Jack Geiger Count Gibson and later the political vision and influence of Senator Ted Kennedy, who devoted his career to fighting for healthcare access. In spite of Boston’s history of racial segregation and cultural and socio-economic division, the Massachusetts League of Community Health Centers successfully mobilized individual neighborhood-led health centers in Boston under a shared commitment to the fight for healthcare access, ultimately expanding that vision and knowledge to other parts of Massachusetts. With this backdrop, community health access has become a cultural expectation and a force to be reckoned with across Massachusetts as health leaders work to implement the broad range of state and federal health reform initiatives aimed at increasing quality, controlling costs and ensuring statewide access to primary care.
Still, the challenge for today’s health centers is to continue to evolve in order to provide relevant and culturally appropriate care to the people they serve. Long-standing health centers like Harbor Health Services and Edward M. Kennedy Community Health Center have adapted to respond to the specific needs and illnesses that affect newer populations in their communities through important partnerships with health center allies, aggressive outreach and creative strategies to providing care. East Boston Neighborhood Health Center, which also serves a multi ethnic and multilingual patient population, has begun to address the socioeconomic factors that affect their patients’ health by expanding their efforts to include economic development and educational training programs. These innovative strategies, and development of the next generation of committed leadership, will ensure community health centers’ relevance and future long term success in strengthening the communities they serve. By Nicole Rodriguez-Robbins