Quality health care for poor people

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Quality health care for poor people

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Title:
Quality health care for poor people
Creator:
Habin, Ronald Ian
Place of Publication:
Tampa, Florida
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University of South Florida
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Language:
English
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xiii, 378 leaves ; 29 cm

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Subjects / Keywords:
Community health services ( lcsh )
Poor -- Medical care ( lcsh )
Dissertations, Academic -- Applied Anthropology -- Doctoral -- USF ( FTS )

Notes

General Note:
Includes vita. Thesis (Ph. D.)--University of South Florida, 1995. Includes bibliographical references (leaves 352-371).

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University of South Florida
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University of South Florida
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All applicable rights reserved by the source institution and holding location.
Resource Identifier:
022113063 ( ALEPH )
35011891 ( OCLC )
F51-00191 ( USFLDC DOI )
f51.191 ( USFLDC Handle )

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QUALITY HEALTH CARE FOR POOR PEOPLE by /RONALD IAN HABIN A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy Department of Anthropology University of South Florida December 1995 Major Professor: Alvin W. Wolfe, Ph.D.

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Graduate S choo l University of South Flori d a Florida CERTIFICATE OF APPROVAL Ph.D. Disserta tion This is to certify tha t the Ph.D. Dissertation of RONALD IAN HABIN with a major in Applied Anthropology has been approved by the Examining Committee on October 6 1995 as satisfactory for the dissertation requirem ent for the Doctor of Philosophy degree Examining Committee: Major Professor: Alvin w Wolfe, Ph. D. Member: Michael V. Angrosino, Ph.D. Member: Joan Bezon. Ph.D. Member: Sue V. Saxon, Ph.D. Member: Patricia Waterman, Ph.D.

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Ronald Ian Habin 1995 @ _________________________________________________________ All Rights Reserved

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DEDICATION Alice J. Ferris Habin, M.D. and Leon Habin This dissertation is dedicated in loving spirit to my mother Alice. She taught me to aim for the pinnacle and always do my best. And then do it again! This dissertation is dedicated to my wonderful father Leon. His is a gentle, yet firm presence whose hand I always feel at the base of my backbone lovingly urging me forward.

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TABLE OF CONTENTS LIST OF TABLES LIST OF FIGURES LIST OF ABBREVIATIONS PREFACE ABSTRACT CHAPTER 1. INTRODUCTION Research Question Definition of Quality Health Care Definition of a Community Health Center Research Limitations Significance of the Study Applying Anthropology for Change Going Public Progeny Going to Work CHAPTER 2. LITERATURE REVIEW Organizational Birth, Growth, and Nexus Nexus Accessibility Systemic Cost Effectiveness Ethnically Sensitive and Neighborhood Wise CHAPTER 3. CULTURE OF THE COMMUNITY Welcome to the Neighborhood The Community Health Care Condition Community Politics-A History of Struggle Separate and Unequal i iv vi vii viii xii 1 2 2 12 15 16 16 17 18 18 20 22 34 44 69 87 129 129 133 135 138

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Pastor Power Other Helping Organizations Culture of the Community 139 141 143 CHAPTER 4 METHODS 146 Obtaining the Internship 148 The Setting 150 Establishing an Identity 150 Data Analysis 152 My Activities 155 Writing Grant Proposals 155 A Patient Satisfaction Survey 156 Internist a s Client 157 Social Service 158 Marketing Effort 158 Note Taking 159 Interviews 160 Drawing (Or At Least Doing My Best) 161 Photography l62 Map Reading 163 Bearing Witness 164 Comparison of Official Documents with Research Analysis 164 Experiencing the Neighborhood 165 Assignment Specific Investigative Queries 165 Research Limitations 169 Conclusion 170 CHAPTER 5. FINDINGS 1 7 2 Organizational Birth, Growth, and Nexus 173 Nexus 194 Accessibility 204 Systemic Cost Effectiveness 217 Ethnically Sensitive and Neighborhood Wise 235 CHAPTER 6. DISCUSSION 282 Definition Comparison 282 Literature Review Comparison 304 Research Question: Experiential Answer 315 CHAPTER 7. IMPLICATIONS FOR APPLICATIONS 316 Suggestions for Future Research 318 Employed Applied Anthropologists Serve Community Health Centers 322 CHAPTER 8. COMMUNITY HEALTH CENTERS IN THE EMERGING PUBLIC POLICY ENVIRONMENT 332 ii

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REFERENCES APPENDICES Struggles Old and New Community Health Center History Review Community Empowerment to Family Values The Legislative Agenda Changes Indicated by This Research Conclusion APPENDIX 1. PATIENT SATISFACTION SURVEY iii 332 333 335 340 343 349 352 372 373

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Table 1. Table 2. Table 3. Table 4. Table 5. Table 6. Table 7 Table 8 Table 9. Table 10. Table 11. Table 12. LIST OF TABLES Infant Mortality Utilization of Health Services by Elderly Poor and Near Poor The Effectiveness of CHCs and Medicaid on Prospective Low Income Patient Use of Health Services Ethnicity of Community and Migrant Health Center Clients Estimated Insurance Expenses for the United States Trends in Cancer Survival Rates by Race (1983-1988) Proportion of Cumulative Aids Cases, Reported Through 1991 A Two-County Comparison of Proportion of Cumulative Aids Cases, Reported Through 1991 A Two-County Profile of Reported Infectious Syphilis-1991 A Two -County Profile of Reported Gonorrhea-1991 Measles (Rubeola) Incidence Per 100,000 Population by Race and Sex, Florida, 1990 Years of Potential Life Lost By Cause Of Death and Race Group, Per 100,000 Population, Ohio, 1984 iv 45 54 60 65 72 91 92 93 94 95 96 99

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Table 13. Table 14. Table 15. Table 16. Table 17. Table 18. Table 19. Table 20. Table 21. Table 22. Table 23. Table 24. Table 25. A Ranking of Serious Health Problems as Perceived By Several Miami Ethnic Groups The Ethnic Categorizations of the U.S. Population and the Population Attending Community and Migrant Health Care Centers 104 124 How Clients Have Heard About The EP Center 184 Statement of Support and Revenue and Expenses 187 Total Encounters by Pay Type 188 EP Client Care by Medical Practice Category 197 Mo.st Important Feature of a Health Care Clinic 214 .Major Annual EP Cost Centers 221 EP's Standard Fees Per Service 222 "What You're Saying" 255 Reasons For EP Client Visits 269 Client Choices for EP Social Service Expansion 273 Client suggestions for The Improvement of EP Services 275 v

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Figure 1. Figure 2. LIST OF FIGURES The Evelyn Perry Community Health Care Center (First Version) The Evelyn Perry Community Health Care Center (Second Version) 189 190

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LIST OF ABBREVIATIONS CHC Community Health Center EP Evelyn Perry (Community Health Center)

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PREFACE This work could not have occurred without the open ended generosity of the Executive Director of the community health center in which I served. He was informative and generous with his valuable time. I learned so much from his community experience and his thirty year health care perspective. Thank you for a very special opportunity. I wish to thank the center's staff for giving me their time and in many cases, their friendship. Because of the assistance of so many, I had the opportunity to view the center, and occasionally help out at many levels of responsibility. You all do blessed work. There are countless people from the community who were helpful respondents. At this time, I recall profound conversations with clerics, store proprietors, a chef, a member of the budding African American Chamber of Commerce, a dance hall instructor, a bell hop, and some too good soft ball players. Thank you for sharing. I have had the honor of listening to literally hundreds of clients over a time span of nine months. We have conversed in many venues. On a number of occasions, I was even invited into your homes. You have taught me so much. You must be the viii

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center of attention. You are what it's all about. May it get better. If it were not for the positive cajoling of Dr. Carol Law Trachy, I would never have even attempted to return to graduate school after a ten year hiatus. You helped my intellectual curiosity get the better of me again and for this I am eternally grateful. Thank you as well, for all of your positive support throughout the process. Dr. Alvin w. Wolfe has been my mentor a decade before he even knew of my existence. Back in the 1970's, I was lucky enough to be in an anthropology department which really valued his path finding work. Back then, I read it all, but I never dreamed I would ever as a graduate student, get to know this preeminent scholar. I am grateful to Distinguished Service Professor Dr. Alvin W. Wolfe as in addition to his frightfully busy schedule, he has been attentive to my work, informative in his critiques, and as always, extremely kind. I am grateful to Dr. Michael V Angrosino. I can honestly say that I have never worked harder on course work in my life for any professor in my 327 year academic history. He simply brings out the very best in his students. I always want to rise to his lofty standards. I am in good company when I say that few can. He has helped me to focus my thoughts, organize my work, and to care as I never before have. Dr. Patricia Waterman is a very special person and professor of anthropology. I have never come across anyone who ix

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simply spreads more joy about doing anthropology than Dr. Waterman. Her enthusiasm is contagious. From Tampa and Ybor City, to the Florida Folk Festival and to your television set, she is the pied piper you simply must follow. She is sneaky too. I have worked hard in her classes ,learning invaluable technique but I didn't know I was working. Her encouragement has helped me strive on in the dissertation process. Dr. Sue v. Saxon has offered me advice and counsel over a period of nearly four years. She had been informative during the period of time when I was a student working in the department of gerontology. She was helpful too, during my community health center internship. I am grateful that she has agreed to offer her insightful critique of this work. I am extremely flattered that Dr. Joan Bezon has agreed to join this dissertation committee. Three years ago Dr. Bezon wrote an important dissertation entitled, An Ethnographic Approach to Health Needs Assessment of Rural Elderly. In this work, Dr. Bezon portrayed some of the difficulties elderly people of a rural Florida county had in obtaining adequate health care. In a scholarly and constructive manner,. she offered helpers who followed, important ideas as to how her studied population might have a better chance of obtaining this care. I appreciate her commitment to "her people." Her work influenced me three years ago as her enthusiasm and insight motivate me today. X

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Getting near the end of a doctoral program takes nearly everything you've got. I suggest that doing it without the help of student colleagues is not possible. I am blessed that I will call many, life long friends. I wish here to publicly acknowledge the following special people: Dr. Honggang Yang and Jie Yang, Susie Xu Hamel, Judy Vittucci, Dr. Alesia ScottFord, Dr. Cheyrl Rodriquez, and Dr. Angela Scoggins. Reuben Sparks is a dear friend and confidant who has always helped me to keep my head while I was losing mine. Dr. Evelyn Phillips is a spiritual sister. Her strength, her courage, her integrity, her scholarship, and her fundamental love of humanity leave me breathless and ever hopeful. Dr. Patricia Lagrua Salmon ... healing happens here Annette Gluskin-Habin is the love of my life. Thank you for being supportive of this effort and allowing me the space to succeed. xi

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QUALITY HEALTH CARE FOR POOR PEOPLE by .RONALD I. HABIN An Abstract Of a dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy Department of Anthropology University of South Florida December 1995 Major Professor: Alvin W. Wolfe, Ph.D. xii

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Low income Americans do not have adequate access to medical care. A major reason, of course, is that given the predominance of expensive private care providers, most poor people cannot afford the luxury of preventive medical habit. By necessity, the daily struggle for food, clothing, and shelter must take precedence. Low income people generally encounter systemic obstacles when seeking quality health care from private medical practitioners, hospital clinics and emergency rooms, as well as from municipally controlled health department facilities. The purpose of this study is to try to improve the lives of low income Americans. When a given population is in good health, it has at least the chance to reach its highest human potential. This effort is primarily an exploration into an institutional means by which practical, humane health care policy may be nourished. That which is to be tested, is the research question: do nonprofit community health care centers offer quality health care to low income Americans? Anthropological theory supports our understanding of how macro and micro ecological influences permit the birth and development of just such an institution. A qualitative research approach is employed, as this seemed to the author, the most informative means by which to learn of the value of one community health care center to its environs. It is the customary job of the anthropologist when going on site, to observe, analyze as best one can, record xiii

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data, e vents and feelings, and then formulate ideas regarding the field experience. This is ethnography. The ethnographic methodological approach is purposefully appropriate. In this endeavour, a variety of traditional investigative techniques are employed. As a result of this study, several themes have emerged. First, a particular community health care center provides quality health care for its client population. Second, due to the success of this institution, it is likely tha t other community health care centers can improve the health care outcomes of different vulnerable populations. Finally, recommendations are made concerning the place of community health centers in the American health care delivery mix. Abstract Approved: Major Professor: Alvin w. Wolfe, Ph.D Distinguished Service Professor, Department of Anthropology Date Approved: xiii

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CHAPTER 1 INTRODUCTION In America's poorest neighborhoods, people have tended to seek medical attention on an as needed basis. It seems that food, rent, clothing, and the electric bill take precedence. Low income Americans do not have the same opportunity for a heal thy life as do middle income or weal thy people. Their lives are by and large, shorter and fraught with more severe illness episodes. The problem and the disparity are getting worse. Each year in this country, one million additional people lose their health insurance. Presently 37-million Americans have no health insurance (Clinton:1993). An additional 17-million people are classified as "underinsured" (Public Citizen Health Research Group 1993:1). As the cost of medical care continues to rise, the under-insured can quickly become poor. The purpose of this study is to try to improve the lives of low income Americans. When a given population is in good health, it has at least the chance to reach its highest human potential. This effort is primarily an exploration into an institutional means by which practical, humane health care policy may be nourished.

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2 As a working applied anthropologist, I believe that my first allegiance should be toward the institution with which I was associated. Traditionally, applied anthropologists represent ''their people." Therefore, this writing will hopefully aid the cause of nonprofit community health centers in their ability to provide at least medical services to low income people. Research Question The question I wish to address in this writing is: Do nonprofit community health care centers offer quality health care to low income Americans? Definition of Quality Health Care To best answer this question, the author offers a definition of quality health care. It is so defined ... Quality health care for a low income person features an accessible neighborhood facility, where a familiar health provider-patient relationship can be established so that preventive life care habits are encouraged.

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3 Quality health care means that health care providers must be ethnically sensitive and neighborhood wise so that dynamic community conditions such as 1 for example 1 lead based paint ingestion, domestic violence, and the rise of HIV, may be considered in effecting health care outcomes. Health care providers must be cognizant of community service delivery issues such as transportation hours, as well and convenient operational as physician time spent with patients. Timely and suggestive patient feedback must be encouraged so that dynamic community health care and particularistic patient care issues may be included in the provider's never ending effort at service delivery improvement. The care giver must be perceived by the community as a permanent fixture offering continuous service upon which people may rely. In this regard, the provider must possess a lasting source of funding support. Its means of financial maintenance must be known by the community it serves. Further, in view of the

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4 escalating costs of medical care in the United States, the cost effectiveness to the patient and to the entire system of medical delivery must prove significant. The institution engaged in dispensing quality health care shall be advantaged if it has an understanding of its financial environment. This means when necessary, the organization must have a working relationship with federal, state and local government. Yet even these relationships, though vital, may not be enough to ensure needed growth. In this regard, a knowledge of and a relationship with germane nonprofit organizations whose job it is to dispense monetary largesse can prove important. In addition, an understanding of which other care givers in their local community have the ability and desire to provide financial, or organizational assistance is necessary if the health care provider is to serve more community residents. And as for those constituents, they too, even in predominantly low income communities, can be a source of financial support. The provider can seek out well endowed local community

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5 benefactors. Further, public fund raising events can not only raise some money and provide health screening, but can offer the sponsoring institution public visibility and in many cases succor a community's emotional attachment. Quality health care means that the provider has the knowledge and ongoing ability to efficiently intervene in the community to change and improve people's health care and life style habits. It means too, that representatives of the health care institution have the knowledge and skill to offer clients social service assistance. In this manner, the health care organization can act as a patient advocate in, for example, the facilitation of government benefits, client's behalf the acquisition on the of necessary medical equipment, and the knowledge of whom to call to keep a client's electricity on or to connect their children with free clothing. Further, if a patient medical malady, they, is diagnosed with a with the aid of the provider, must be able to network to more condition specific medical attention.

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6 Quality health care understanding that all proceeds from human beings an are entitled to receive timely and ongoing medical attention in a familiar patient-provider relationship. It means too, that it is better to treat people before they get sick. It also means that health care providers must be cognizant of the fact that what good health care is, varies from neighborhood to neighborhood. The presented definition owes its genesis to a variety of sources. Initially, it must be stated that many of the aforementioned ideas have come to me from my own field experience. What better teaching environment for my purpose could I possibly have than a two-semester internship at a community health care center? I note too, that upon completion of my on-site assignment, this author spent a week standing apart from the day to day. work c hallenges and carefully considered the sum of my intellectual and personal training. It is partially from this serious reflection, that the definition o f "quality health care" was crafted. The term "experiential" is like a broad ten t It encompasses much. In this context, I include as experiential, the voluminous reading I did on the subject. Much of my

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7 contemporary reading was generally helpful in setting parameters for the definition. Yet, some of the works with which I came in contact, had specific influence on this final rendering. As I repeat the definition, a few of these will be credited. Keep in mind, however, that much of this definition has emerged from the issues which I thought to be important and from the concerns of real people at one particular health care center. This is legitimate and it is just. Quality health care for a low income person features an accessible neighborhood facility, where a familiar relationship can health provider-patient be established so that preventive life care habits are encouraged. (Wilson: 1970) (Primary Health Care Consortium of Dade County Florida: 1991) Quality health care means that health care providers must be ethnically sensitive and neighborhood wise so that dynamic community conditions such as, for example, lead based paint ingestion, domestic violence, and the rise of HIV, may be considered in effecting health care outcomes. (Wilson: 1970) (Hutchins and Walch: 1989)

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8 Health care providers must be cognizant of community service delivery issues such as transportation and convenient operational hours, as well as physician time spent with patients. Timely and suggestive patient feedback must be encouraged so that dynamic community health care and particularistic patient care issues may be included in the provider's never ending effort at service delivery improvement. The care giver must be perceived by the community as a permanent fixture offering continuous service upon which people may rely. In this regard, the provider must possess a lasting source of funding support. Its means of financial maintenance must be known by the community it serves. Further, in view of the escalating costs of medical care in the United States, the cost effectiveness to the patient and to the entire system of medical delivery must prove significant. (National Association of Community Health Centers: 1991 (2)) (Yang, Shah, Watson, Mankad: 1995)

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9 The institution engaged in dispensing quality health care shall be advantaged if it has an understanding of its financial environment. This means when necessary, the organization must have a working relationship with federal, state and local government. Yet even these relationships, though vital, may not be enough to ensure needed growth. In this regard, a knowledge of and a relationship with germane nonprofit organizations whose job it is to dispense monetary largesse can prove important. In addition, an which other care givers community have the ability understanding of in their local and desire to provide financial, or organizational assistance is necessary if the health care provider is to serve more community residents. And as for those constituents, they too, even in predominantly low income communities, can be a source of financial support. The provider can seek out well endowed local community benefactors. Further, public fund raising events can not only raise some money and provide health screening, but can offer the sponsoring institution public visibility and in many cases succor a community' s emotional

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10 attachment. (Baker and O'Brien: 1978) (Dewalt and Pelto: 1985) (Deroche: 1987) Quality health care means that provider has the knowledge and ongoing ability to efficiently intervene in the community to change and improve people's health care and life style habits. It means too, that representatives of the health care institution have the knowledge and skill to offer clients social service assistance. In this manner, the health care organization can act as a patient advocate in, for example, the facilitation of government benefits, the acquisition on the client's behalf of necessary medical equipment, and the knowledge of whom to call to keep a client's electricity on or to connect Further, medical their children with free clothing. if a patient is diagnosed with a malady, they, with the aid of the provider, must be able to network to more condition specific medical attention. (Lacey, Phillips, Ansell, Whitman, Ebie, Chen: 1989) (Primary Health Care Consortium of Dade County Florida:1991)

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11 Quality health care understanding that all proceeds from human beings an are entitled to receive timely and ongoing medical attention in a familiar patient-provider relationship. It means too, that it is better to treat people before they get sick. It also means that health care providers must be cognizant of the fact that what good health care is, varies from neighborhood to neighborhood. (Weidman: 1978) (Blumenthal, Lukomnk, Hawkins Jr.: 1993) I find it encouraging that many of the provisions of this definition of quality health care are often similar to the ideals and formal Constitution of the World Health Organization. This document which was born in 1946, provides as a major principle, for example, that "the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, or economic or social condition" (1994:1). Amen. Throughout Quality Health Care For Poor People, it is the author's intention to employ anthropological techniques and sensitivities in an attempt to answer whether or not nonprofit community health care centers offer quality health care to low income Americans. The purpose of this study as stated, is to try to improve the lives of this country's most vulnerable

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12 citizens. A condition of good health at least affords people the chance to reach their highest human potential. If in fact, community health care centers do provide their clients with quality health care, then the chances are improved that a variety of medically at risk populations can also be helped. Definition of A Community Health Center Though the history of community health centers will be recounted later in the text, I wish at this time to describe what will be discussed as the subject of this inquiry. The term "community health center" shall refer in this context to a service institution geared primarily but not exclusively to the medical needs of low income Americans. It shall be predominately government funded. The facility should be in localities convenient to medically at risk populations. It must welcome residents regardless of race, sex, age, sexual orientation, malady, or ability to pay. In this writing, the term community health center and not "clinic" shall be employed. You see, community health centers were born in the United states in the mid-1960's as part of President Johnson's "War on Poverty." During that period, it was believed by federal health officials that the term "clinic would be thought of by man y as a hospital outpatient complex. According to Jack Geiger, M.D. (November 20, 1994), the designer of the community health center concept in the

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13 United States and South Africa, the early planners thought it essential to find a different term to differentiate these new organizations from hospital out-patient clinics. Program designers were aware that the reputation of most hospital clinics among the very clients they were trying to reach, was pretty awful (Haendel:l993). Other derogatory references were brought to their attention. Hospital clinics were thought by many to be places for the administration of "charity care'' (Geiger:l994). That's not at all what Geiger and his team had in mind. Clinics were further perceived to be places of inferior care. Again, this was wholly other from the conceived vision of community health centers. One other point is germane. Policy planners believed that the community should be the center of power and operations. Therefore, it was decided that a new term, "community health center" or CHC, would be brought into the lexicon to refer to a new kind of health care institution. Often in this text too, I shall use the term "client" as opposed to "patient." As we have noted, words and their subtle shades of meanings are significant. I perceive the term patient as a person fulfilling a very specific and limited role. The identity is of one being ministered to for the purpose of confronting and hopefully alleviating a medical malady. The term client, on the other hand, has in it, more room for growth. I notice that it seems to have a temporal

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14 component. A "client'' is cared for in a very personable way in order to assure a valued relationship. The word "client" in this context, does imply an ongoing medical affiliation. Yet, I think it says more. I feel that it permits a person additional identity within this primarily medically oriented environment. The term offers permission for a person to assume other roles beyond that assigned to them by the major medical model. For example, they could assume the identity of "student" in a health center sponsored self help class. or, with time, they could become an enthusiastic volunteer whose weekly presence might ease the center's patient file placement burden. The term might also imply a regular donor of goods and services. The term "client" as used here, is a statement of hope. It will come to suggest a community's behavioral change .in regard to its predominant health care practice. The term will more likely be made manifest with the aid of sensitive, professional intervention. The reader will note that occasionally, the word "patient" will be used. It has not been banned. It has only been restricted to use in a narrow, recipient of medical attention context.

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15 Research Limitations The research limitations of this study are identified as follows: 1. Evidence and conclusions shall be derived from the particular instance of my two-semester internship at an urban community health center. The discussion shall be placed within the context of applied anthropological literature as well as in the studies of germane intellectual fields of endeavor. 2. My research interest is in nonprofit community health care centers. In an institution such as this, surplus funds (when they exist) are plowed back into the service of the center. Also, salaries are generally respectable but modest in comparison to for profit institutions. The lack of need to show a profitable quarterly balance sheet, helps keep client fees low. Even with low fees, some destitute patients require free medical attention. The modus operandi of the overwhelming majority of the community centers is to provide care regardless of a person's ability to pay. 3 For profit health clinics are beyond the scope of this research.

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16 Significance of the Study This account is an original inquiry into the use of anthropological theory and method for the purpose of creating a more equitable and accessible health care system for low income Americans. Applying Anthropology for Change The profession of applied anthropology is informed and invigorated by accounts of the work of consummate practitioners. In "Service, Deli very, Advocacy, and The Policy Cycle," Michael V. Angrosino and Linda M. Whiteford demonstrate that skilled agents of change can have the ability to alter the normal governmental hierarchical chain of command to effect the decision making process on behalf of their constituency. For example, a case reported in this account was that of Opportunity House, a temporary living facility for mildly retarded men. Apparently, the main social service agency in its home state of Florida, was on the verge of ending the program. Rather than "taking it lying down," Opportunity House contacted the local media and explained the values and success it was achieving with its clients. Further, it went public to show how a competitive program was not achieving nearly the same results. When the time was right,

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17 and the legislature was in session, Opportunity House officials and clients made their way to the state capital to protest and lobby on behalf of their organization. Opportunity House won the day. Further, as a result of its exposure of the competing less competent subcontractor, the law was changed to permit annual state review of all social service oriented programs. In this matter, the participat ing anthropologist was viewed by decision makers as a legitimate outsider who could analyze the competency of a particular non-mainstream population, as well as the value of programmatic effort. The recommendations of this professional apparently carried great weight as, in this the programmatic vision of the applied anthropologist was enacted. Thus, it is demonstrated, that "applied social scientists can work within the realities of the political system and become effective players in the policy cycle, combining in the process the roles of researcher and advocate" (1987:504). Going Public Upon completion of my research and the formulation of recommendations, I intend to acquaint appropriate public officials and interest groups with my findings. Toward this end, I would plan to meet with and testify before healthcare-related congressional committees. I will seek out interest groups which could benefit from my counsel and from

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18 whose relationships I might benefit. My overall objective is to make a difference in the creation of a more humane health care policy. Progeny I believe that this project is significant to students of applied anthropology. It is my desire that this study contribute to the body of work which demonstrates to those who follow, that the tools of this profession can be used to ameliorate a societal problem. Going to Work Anthropologists possess powerful I wish to demonstrate that when used with care, sensitivity, and respectful aggression, we professionals can achieve results. For example, I believe anthropologists are expert at identifying ways institutions may connect with influential community residents. I think this because we are trained to consider familial and institutional structure. We are also trained to incorporate existing ethnographic literature into our analysis. We take care to identify and understand community signs and symbols. We try to listen. Hopefully, our intervention can serve to make stronger our

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19 institutional employer as we help it better relate to its community. I wish to demonstrate that nonprofit community health centers can play a crucial role in the emerging health care policy environment. I believe too, that you will come to agree that the skills of the anthropologist can positively influence a health center's success and the well being of at risk populations.

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20 CHAPTER 2 LITERATURE REVIEW This chapter will feature the types of literature which will form the intellectual background for this study. Its purpose is to further elucidate the construction and logical flow of my thinking. The text shall be divided into four sections. The first shall be entitled "Organizational, Birth, Growth and Nexus." Here I present literature which will offer the reader a perspective on how an institution such as a community health care center might come into existence. I will indicate too, the particular political, economic, and social milieus which gave rise to the possibility of community health center growth. Additionally, some broad, general, theoretical guidelines are presented which might aid developing organizations gain nourishment from and then better serve their respective communities. The second section shall be entitled "Accessibility." It will feature studies concerned with the issue of different population's ability to obtain health care. As the reader would be first inclined to believe, lack of personal financial resources is a major impediment to obtaining care. Yet other potential obstacles are documented. Among these I include: the

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21 provider's hours of operation, location convenience, suitable hours of operation, transportation facilities, as well as cultural and language barriers. This section also more than hints that (surprise) "government" intervention can positively impact people's access to and willingness to seek out preventive medical services. The title of the third section is "Systemic Cost Effectiveness." Some of the glaring cost inefficiencies of the present major medical health insurance delivery system are presented here. The resulting impact on very real vulnerable populations is also demonstrated. Again surprisingly, "government programs" in this arena are found to be rather efficient supports of needed care. Speaking of government support, community health centers appear to offer the tax paying and insurance premium paying public an effective "bang for the buck" means of providing health care to low income populations. The fourth section is entitled "Ethnically Sensitive, Neighborhood Wise." In this section, I try to present literature which features the importance of a local institution's learning a variety of neighborhood mores in effecting timely and humane health care intervention. States, counties, and communities have different and dynamic health statuses. Different age, sex, ethnic, income and other population variables may lead to divergent community health care perceptions.

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22 Organizational Birth, Growth, and Nexus I suggest that in an internship, the student should initially consider how and why the institution got started. Early on, I was interested in the various milieus ( ie. economic and community) from which this particular community health center was born. This perspective of "cultural ecology" was made popular by Julian Steward. The theoretical orientation of cultural ecology provides the means by which I examine the idea of quality health care for a low income community. Steward's ideas are illustrated when, for example, he discusses a culture' s development beyond hunting and gathering ... More advanced techniques such as metallurgy, are acceptable only if certain pre-conditions, such as stable population, leisure time, and internal specialization were present. These conditions could develop only from the cultural ecological adaptations of an agricultural society. The concept of cultural ecology, however, is less concerned with the origin and diffusion of technologies than with the fact that they may be used differently and entail different social arrangements in each environment (1973:328). Steward' s thinking should lead the reader to consider that local institutions may develop in varied manner, given their immediate organizational "environmental circumstances." Based partially on her work on behalf of a Canadian family planning center, Constance P. Deroche says "an organization' s network of relations is not independent of its

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23 task environment. Where financial support is a major element of that environment, the structure of funding will impact upon relationships among network constituents, helping to define power, competition, and cooperation" (1987:132). In Deroche's on-site work at a Canadian family planning center, she observes how the institution was severely weakened by a change in the macro political and economic power structure. From its inception, the center was able to apply for grants from the federal government in conjunction with its local family planning association. The association was made up of a number of local idealistic gung-ho similar organizations. The association's existence relied on the good will of these local family planning centers. But when funding was transferred from the federal government to the provinces, money flowed directly to these associations and then distributed to members. The status of the various centers changed from cooperative allies to needy competitors. At this time too, each center increased its funding request so as to not fall behind the others. Therefore, the organization where Deroche worked, had to metaphorically grovel at the feet of an association it helped create. Ultimately it was rendered less powerful and administrative and employee morale went from exciting anticipation to free fall. Deroche well illustrates that organizations are vulnerable to changes in their macro environment.

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24 Speaking of organizational vulnerability to larger and more powerful systems, I believe this to be an appropriate juncture to mention why I chose what some believe to be the value neutral theoretical orientation of .cultural ecology in this study of poor people's access to basic health care. After all, at this writing, there is disagreement of approach in medical anthropology between traditional cultural ecologists and the more recent adherents of "critical medical anthropology" (CMA). In this context, an astute reader might believe that the chosen theoretical orientation might seem incongruous and therefore, ineffective, toward the stated purpose of this study which is to try to improve the lives of low income Americans. Critical medical anthropologists contend that as cultural ecologists (or as often referred to in this context, medical ecologists) fail in their work to consider that larger issues of racism, class ism, and sexism are by-products of world capitalist systems (Singer:1989), they have actually legitimized inequities in social relationships. In a sense, it is said that they have smuggled in a conservative slant to supposedly "value neutral science." CMA advocates contend that by merely observing "what is," from the theoretical orientation of medical ecology, one could rather easily conclude that subordinate groups have merely maladapted to their environment. In the parlance of today's political

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25 vitriol, one could therefore conclude that their condition is the "unfit" victim's fault. The purpose here is not to attack critical medical anthropology. In fact, I believe it can be advantageous to a studied population for a practitioner to consider as criteria, the degree to which a supposed helping institution responds to political and economic pressure at the expense of tangible local need. My goal is to demonstrate a congruence between a cultural ecological theoretical perspective and an envisioned hope of social change. First, in the context of the aforementioned CMA critique, I believe the reader will find that I have placed the studied community health center within the framework of the government macro system. The means of governmental authority over this small institution will be demonstrated. I leave it to the reader's judgement whether or not the government's power locks in a condition of reactionary subordination or instead permits possible popular progressive change. Secondly, I believe the cultural ecologist can observe and communicate whether an environment is in stasis or rather in a condition of dynamic change. The reader may upon the completion of this text, conclude that local health care needs are not stagnant. People's responses to their changing environment are not stagnant either. Instead, "adaptation can reflect the dynamic relationship between the environment,

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26 individuals, and communities ... it is an active process that engages individuals and groups in the struggle for their health" (Wiley 1992:216). In this spirit, this work may suggest ways in which a community institution can respond to ever changing health needs. I do not believe that the two domains of inquiry should be seen as working toward opposite ends. In this context, I report that Merrill Singer says that "because they admit to having values,. critical medical anthropologists are seen as unduly biased in their treatment of research findings" (1993:186). In my opinion, critical medical anthropologists are not unique in having values and therefore biases. I have them and freely admit that I am biased in favor of the health center in which I served. I am very biased in favor of the health center's clientele. Either perspective in this case would I think, alert the reader to some very serious social inequities. In this study, for example, I believe I have assembled some rather telling statistical and experiential data. The still "snapshot" should if I'm effective, communicate the difficult conditions of living in this particular environment. I leave it to the reader's opinion whether this author presents client conditions as somehow their environmental maladaptation. In a more positive vein, the reader is encouraged to consider variables such as race, class, and sex as descriptions of health center personnel are presented vis-

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27 a-vis neighborhood health care requirements. sometimes, I think, without critical bent, the practitioner need merely tell the story. In this case, I hope that by observing and telling what I found, like bas-relief, a dramatic image will be presented. It is my hope that this work is but small evidence that a cultural ecological theoretical perspective can rather strikingly display the need for dynamic social change. As long as there are remaining resources, local organizations are not necessarily consigned to the role of compliant loser. This view is bolstered by researchers Billie R. DeWalt and Pertti J. Pelto when they contend that "the microlevel is not passively shaped by macrolevel forces, but reacts to these forces, often in ways that change the larger s ystem ( 1 985:5) The authors understand and perhaps state the obvious when they say that the larger system often imposes s ignifican t restraints. Yet, they believe that local people do find it possible to select from among a variety of alternative solut ions or to even create a new solution within the sociopoli t ical and t heoretical framework of macrolevel necessi t ies. To analyze the potential growth a n d effectiveness of an institut ion, the researcher must consider vari a bles such as: organizationa l construction, internal power f low, likely and actual relationships to other institutions, and the institution's potent1al relationshi p to the still w ider

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28 national social, political, and economic milieu. I am informed in this regard by the work of Alvin w. Wolfe, a pioneer of networking methodology. He advises: "networks emerge from social interaction, are generated over time in a series of ongoing transactions among social actors, and are maintained in a variety of institutionalized forms because they have some adaptive value for the populations practicing them" ( 1991:17). Therefore, an important part of this work will be to explore with whom community health centers cooperate (and not), and with whom future common cause may be explored. In consideration of the wider environment, I feel it important to research and include background on the founding and present day performance of government Medicare and Medicaid programs. If these programs did not exist, neither would most nonprofit community health centers. The Social Security Act was developed by the Roosevelt Administration. The politically adroit President presented Social Security, not as "welfare," but as a personal contribution program. He believed that the American people would only accept a government induced program if it did not violate our cultural sensibilities concerning the Calvinistically induced moral value of "self reliance." Francis L.K. Hsu wrote of the exaggerated sense of self reliance in the United States. In discussing its implications, he notes:

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29 The English have been able to initiate a sort of socialism in reality, as well as in name, but regardless of social security, farm subs1d1es, welfare, Medicare, and other forms of government planning, intervention and assistance are as f1rmly as ever committed to the idea of free enterprise and deeply intolerant toward other political and social systems (1972:249). As usual, Roosevelt's P9litical instincts were correct. His income maintenance plan was helped along too, by moderately more accepting attitudes induced by the Great Depression. As a result of wide spread economic calamity, seniors themselves felt that this government induced program was at least palatable. Gerontologist Stanley Brody calls the plan to help prevent old people from falling into abject poverty the formal avoidance of "the first catastrophe" (1987:132). That is, unlike Europe, American policy toward seniors has been one of merely helping t .hey and their families avoid the most obvious paths to economic ruin. By 1965, the political environment was somewhat changed. The President was Lyndon Johnson who was regarded as a domestic and social liberal. The national treasury also enjoyed a healthy surplus. The new political environment was also formed by an increasing number of elderly Americans. By the mid-1960"s, the elderly represented ten percent ( 20 million) of the total U.S. population. Medicare became law in 1965. It's purpose was to help the elderly avoid what Brody has called "the second catastrophe." He wrote, "older people's lack of resources with which to purchase acute medical care" (1987:133). Medicare was to be

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30 paid for from a variety of income streams. Part of the funds were to come from the Social Security trust fund. For the first time too, funds would be ear marked for seniors from general revenues. This was new business. Finally, some of the costs such as deductibles and co-payments were to be paid by the elderly patient. Incidently, the American Medical Association was instrumental in inserting a "reasonable fee" stipulation into the legislation. This little provision permitted doctors to charge what they thought was reasonable. They would then be reimbursed by the government. Also in 1965, Congress enacted Medicaid. According to Stanley Brody, Medicaid became law to fend off what he calls the third rna jor catastrophe; the need of th e new "old-old" population for long term care. Medicaid though, is not age specific. The program is financed from general revenues of the federal and state governments. Thus recipients in different states must meet varying income requirements in order to receive benefits from this means tested program. Disparity of benefits exists among the states. Under Medicaid, the states (with federal assistance) are obliged to help people pay for such services as; inpatient and outpatient care, physician services, x-rays, and skilled nursing home care. Yet such needs as prescription drugs and dental care remain state optional. Another problem is that prices for long term care and physicians are determined by a

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31 fee structure. Therefore, some physicians who, when given the choice, view Medicaid and Medicare patients as a lower priority visit than "full paying" patients. Also, the paper work associated with said programs a time consuming obstacle many medical practitioners would really rather avoid.' Medicaid has been subjected to political whim. In 1981, Congress enacted the Reagan Administration's Omnibus Budget Reconciliation Act, or OBR.A (US PL 97-35). The act reduced the amount of federal funds to three percent below those previously authorized. The act also permitted the states to adopt more stringent eligibility criteria for specific subgroups and to limit certain services. Given the enactment of the 1981 federal policy, most states restricted the scope of benefits provided. The number of hospital days covered by Medicaid was reduced, and the total number of monthly patient visits to the doctor declined (Harrington, Estes, Lee 1986:440). As this macro health care environment has been described, it is now appropriate to discuss the birth and growth of nonprofit community health care centers. Not surprisingly, the idea for their permanent federal support for same came out of the Johnson Administration's War on Poverty. In 1964, the Office of Economic Opportunity (OEO) was born. From this agency and the vision of Senator Edward M. Kennedy (D-MA), came ''research and demonstrations projects." One was located in a public housing project called Columbia Point located just

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32 south of Boston. The other was placed in an impoverished rural area, Mound Bayou, Mississippi. According to a knowledgeable and helpful informant who was an OEO policy planner at the time, the two centers were well funded and had many clients. However, because federal budgeting was and always will be problematic, the Washington bureau had trouble performing adequate quality control for these projects. Specifically, the agency travel budget had been cut a n d so there was little on-site inspection permitted. It is ironic that partially as a result of budget constraints, more local District of Columbia community health centers were created. Additionally, in 1966, Senator Kennedy sponsored an amendment (42 u.s.c. 2809) to Section 222(a)(4) of the Economic Opportunity Act, which appropriated $50 million dollars for nationwide community health centers. By 1970, 100 OEO funded community and migrant health centers were providing care. The centers were charged with providing comprehensive health services to all residents of a community, regardless of their ability to pay. By most accounts, the centers were performing well and it was thought they had many proponents. However, in 1973, with the advent of a new Administration, the Office of Economic Opportunity was eliminated with poor person's health care responsibility transferred to the Department of Health, Education and Welfare. The new executive branch policy planners believed

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33 that health care for poor people was a state responsibility. No new health centers were to be funded. Therefore, funding availability as well as philosophical intent became less consistent. Ultimately, the Congress prevented the Ford Administration from the total financial abandonment of community health centers. Today in the 1990's, with federal funding for community and migrant health centers lagging inflation, and health care costs running consistently ahead of inflation, there are actually fewer such institutions than a decade ago. In 1980, there were over 800 CHCs in the United States. Now in the early 1990's, there are only 547. Yet the ideals which gave birth to the community health center movement in the 1960's seem in many ways to have survived adversity. According to the mission statement as enunciated in Health Care. Access and Equality, a publication of the National Association of Community Health Centers (1990), the providers must be committed to: -rendering health care to a population or area that has been federally designated as medically underserved -provide family-oriented primary health care which will include basic medical and laboratory services, as well as support in the delivery of preventive health and social services -being governed by a community based board of directors, the majority of whom will be center clients -being administered by an executive director, responsible to the board of directors -employing highly qualified medical and clinical staff

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34 adjusting the cost of their services according to the patients ability to pay -to the extent possible, providing all services under one roof thus emphasizing constituent convenience Nexus I wish to make clear what Nexus means in the context of this text. I employ it to mean the connection of a community health center to its potential and active clients, its relationship with other community organizations, and the understanding of and the adaptation to neighborhood values for the purpose of institutional nourishment and continuity. In this way, the micro environment will permit a community health center to mature. Further, when ongoing ties are established, the environment may suggest to the health center, efficient policy choices which should improve the institution's ability to make manifest the ideals upon which it had been created. The literature references which follow are germane. One important way for a CHC to achieve value cohesion with its neighborhood is to understand the personal ties upon which communities are based. Such relationships as family, co-worker, fellow church parishioner, or membership in the same association or a mixture of the above (multiplex ties), are examples of strong ties of affiliation. Anthropologist Susan D. Greenbaum (1982) has discovered that these relationships also can lead to networks of power outside of a poor or

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35 working class neighborhood. Therefore, the exercise of these networks seem to be an excellent way to enhance community cohesion and build local political strength. Also, familiarity with these networks can efficiently build a health center's clientele. Greenbaum and Greenbaum (1985) relate that residential proximity is the most important variable when it comes to with whom people spend time. For ethnically heterogeneous neighborhoods, "face block relationships'' account for a very large proportion of personal association. In ethnically homogeneous neighborhoods, however, people are more likely to form off block bridging ties. The author's data seem to open the way for the creation of. or an intervention with neighborhood block associations. Also, church attendance was found to increase neighborhood network ties. These relationships do supplement face block connections. The twin indices of value congruence and social compatibility which help account for church attendance may be used as an organizing tool for a health center and a neighborhood. Gerontologist Laurie Russell Hatch (1991), has done some sensitive work in trying to discover the differences between helping resources for older African American women and senior white women. Among the author's testable hypotheses, she sought to learn whether religious participation would be a

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36 stronger predictor of informal support patterns for older African American women than for older white women. Hatch found that attendance at religious social events was the most important variable in predicting the selection of helpers for older African American women. It seems that higher church event attendance was associated with a lower likelihood of asking children for financial assistance. It seems that for older African American women, religious social event attendance was the crucial variable in predicting the selection of non relatives as helpers. This was not true for older white women. At the conclusion of her important article, Hatch recalls that traditionally, family members have constituted a domain of involvement separate from friends and neighbors. The author says this assumption may be less valid for African Americans. Hatch suggests that in the African American community, friends are often integral parts of people's support networks, and may come to be viewed and treated as extended family. In this work, the author finds that white women were much more likely to seek help from their children during financial crises. I should think a helping community organization would do well to understand and make use of these distinctions. If aoo were to initiate a strategy of organizing community churches, one had better have a reasonable understanding of likely institutional organization and accompanying networking possibilities. For example, we are informed by Jane W.

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37 Peterson (1990) that women of authority called "Mothers" in the black pentecostal churches wield considerable social and economic power. They have achieved title and status by long term demonstration of faith. Frequently, they are the gatekeepers of significant resources which may be dispersed within the prescribed social network. Social service employees would be wise to befriend some of these women. Maria G. Borrero, Jean J. Schensul, and Robert Garcia ( 1982) demonstrate the advantages of employing university trained local residents to inquire of and ultimately impact health care conditions in a particular ethnic community. They suggest that every community has natural spokespersons who are skilled at speaking on behalf of their community. The authors say that if they can be university trained in the ways of, for example, data collection, their efforts would have far greater impact. The Hispanic Health Council of which author Schensul is a director, is a Puerto RicanjHispanic community based organization in Hartford. Among its raisons d'etre are the collection and analysis of community health care information. It seeks to find gaps in local delivery systems. The council brought together university trained researchers, anthropologists familiar with other "Latino urban communi ties," and neighborhood people with a background in community organizing. These residents were helped in their

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38 efforts in interviewing their neighbors as well as in interviewing staff members of the local hospital. The new researchers discovered that hospital staff was not fully cognizant of some identified neighborhood values. It was found for example, that some service providers believed there was little or no variation in family structure, economic supports, language use, and other important socioeconomic and cultural factors in the Puerto Rican community. They also did not tend to believe that family life or other environmental factors bore any relationship to patient well being. In general too, they seemed to be ignorant of common community support services or agencies utilized by their patients. Hospital staff expressed little interest in learning of the importance of the patient's family, the significance of community leaders, or of the meaning of espiritistas to their patient population. Therefore, they could not understand why so many of their Puerto Rican clients came to the hospital accompanied by other family members. They also did not envision the problem of "lack of continuity of care.". They didn't know that this was as much the result of the way in which the hospital and the health care system in general were organized as the community residents' lack of experience negotiating it. By interviewing neighborhood residents, the community wise researchers reaffirmed that Puerto Rican patients usually opt for home remedies before using other resources.

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39 Interestingly, the researchers' findings were juxtaposed with family and household data to show that surveyed families frequently only had the economic, social, transportation, and baby sitting resources to support one emergency room visit. This finding can go a long way toward explaining the frustration of the hospital worker who believes Puerto Rican patients want immediate relief, medication, and rapid treatment. Hispanic Health Council training of researchers included ways they could teach hospital employees to avoid stereotyping by focusing on intra-ethnic diversity in a wide variety of Puerto RicanjHispanic health care beliefs. At the same time, sensitivity to the plight of hospital employees was emphasized. Particularly, team members were instructed in some of the difficulties faced by hospital personnel in attempting to provide adequate service to Puerto Rican clients. This was done with a cognizance of trying to create change in am institutional setting not easily reformed. Otitis media is an acute infection of the middle ear affecting children between birth and age six. The affliction requires constant moni taring and follow-up to ensure the disappearance of the initial infection. Yet, it most cases, it is relatively easily treated with an antibiotic. The researchers in this Hartford community learned that otitis media was the most frequently reported childhood disease. On the other hand the researchers did not know how the disease I

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4 0 was perceived and managed in the community which led to speculation that clinic data did not accurately represent disease incidence. Intuitively, it was believed that actual incidence was even higher than reported. A health care policy change was effected at the hospital clinic as pediatric checking for otitis media became a priority. During patient visits, health care workers listened to detailed patient history and otitis media symptoms. At this appointment, patients are provided information about the disease. Follow up calls are made to ensure patient medication compliance and to remind parents of the next appointment. Sometimes a third otitis media appointment is i ndicated. Significantly, the disease is no longer treated episodically but as a chronic community affliction. Also important, is the fact that during patient visits, hospital clinic staff work hard now to link the child's family into other available health services. The above change model combines research, training, assistance, and advocacy in a single program directed toward effecting service systems which aid individual patients. The authors believe this model can be best implemented when there is in existence, a permanent community institution which will ultimately have responsibility to monitor, train, advocate, and maintain continuing involvement in the change process. The authors conclude their analysis by making what I believe to be an important systemic point. They say that a

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41 central element in the Hispanic Health Council's approach to long term change is its policy of collaborating in important program efforts with other neighborhood institutions. The Council seeks out what are described as "sympathetic sectors" whose administrators see it in their best interest for either political or economic reasons to join forces in particular efforts which assist the Puerto Rican community. Ethnic specific and neighborhood specific knowledge is shown to be crucial information to have if health care providers are to offer optimal and efficient care. In a provocative article by Jean J Schensul, Iris Nieces, and Maria D. Martinez {1982), it is demonstrated that in Hartford, newly arrived former residents of Puerto Rico were being inappropriately placed into psychiatric institutions because neither the local hospital emergency room personnel, nor the city police were equipped with bilingual systemic negotiators. The authors note that the police connection is important as people of Puerto Rican descent frequently use this resource first in the event of a psychiatric health emergency. The aforementioned Hispanic Health Council combined efforts with the police department to achieve a grant from National Institute for Mental Health for an intervention plan called The ARRIBA Project. The modus operandi combines the resources of the police, a local hospital emergency room, and a trained community advocacy team connected by a 24 hour telephone hot line.

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42 When a call comes in to any of these partners, the community advocate goes immediately to the scene of the emergency. If for example, the call comes from a horne, the bilingual advocate assesses proper remedies or placement. Further, the advocate tries to identify family members who may, throughout the experience, be called upon to aid the person in crises. This may include having the family member becoming themselves, an ally and advocate over a prolonged period of time. The authors note that this familial connection makes sense to people of Puerto Rican descent, as family remedies are almost always tried before formal systemic "cries for help." Finally, the ARRIBA staff person is expected to advocate and help negotiate the needed formal institutions on behalf of the client until the distress is resolved. The ARRIBA Project identified the most frequently used resources in this Hartford Puerto Rican neighborhood. These included: family members, community oriented Catholic churches, the police department, Hispanic merchants, espiritistas, and some individual advocates. The project was helpful in binding these resources to formal helping service organizations. Yet network stability is best insured in this neighborhood by the combined efforts of the advocate with the dedicated (preferably bilingual) family member. Without familial support, the active use of the network is more likely to be short lived.

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43 Finally, the authors point out that knowledge of the local population's particular "stressors" can make health care providers more effective. For example, if one learns that many local residents are newly arrived, you would expect that they would have little knowledge of how to negotiate the formal health care system. Also, if a high percentage of households are managed by a single female parent, one can become aware of particular potential vulnerabilities. It seems that local knowledge based interventions by an ongoing "project" or institution, can prove to be a powerful neighborhood resource. In an important article on interorganizational relationships, Frank Baker and Gregory O'Brien (1978) provide a helpful portrait of how established social service organizations similar goals grow. will They be relate that competitive. organizations with Their degree of competitiveness depends on the quantity of resource base. Yet, they say two organizational systems can and do form alliances due to complementary role expectations. Therefore, it is likely that several organizations may apply together for a multifaceted grant. If these would be grantees had similar needs, or could be made aware that each had common outcome expectations, it is likely that they would grow and benefit from each other. applied anthropologist might be Perhaps one role of the facilitation an of complimentary goals between institutions within the health and human services milieu.

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44 Accessibility A vi tal component of the measure of "quality health care," is accessibility. Further, it is helpful to examine which particular groups of people are being presumably harmed by built in barriers to care. Sociologists Daniel 0. Clark and George L. Maddox (1992) examined social and racial differences in age-related changes in functioning. blackjnon-black, The studied categorical pairings included: poorjnon poor, male/female, and high school/non-high-school graduates. It is reported that African Americans were in poorer late life functional status than non blacks. The most significant variable which accounts for this difference is income or in this case, limited income. A second variable of importance is educational attainment. Yet the effects of income differential and educational attainment (both a likely byproduct of American societal racism), do not fully account for the differences in late life functional dependence. In this matter Clark and Maddox suggest that "a greater incidence of chronic disabling diseases which may be in part the result of an inability to purchase timely, quality health care as well as the effects of livingjworking conditions and certain lifestyle and psychosocial factors combine in complex ways ( 5231)" to disproportionately impair African American people.

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45 At the CHC in which I experienced my internship, approximately two-thirds of the clients were African American. Thirty percent were white. Appropriately then, I explore African American and white persons health. data. A report issued from the unusually sensitive and active Ohio Commission on Minority Health is helpful. Entitled The Governor's Task Force on Black and Minority Health (1987), it offers a poignant window on disparity. An example is its Infant Mortality Table: Table 1. Infant Mortality Total White Black Infant Deaths per 1,000 10.4 9.2 17.6 Neonatal Deaths per 1,000 6.7 6.0 11.1 Post Neonatal Deaths per 1,000 3.7 3 2 6.6 (vii) Not surprisingly, excess minority infant deaths were noted in each of the state's urban metropolitan areas. For example, in the predominantly black neighborhoods of Cleveland, minority infant deaths occurred at a rate of up to four times that of the state average. The Ohio Task Force also measured "Years of Potential Life Lost by cause of Death and Race Group Per 100,000

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46 Population" (12). Black years of lives lost as compared to whites was twice as high for the following diseases ... Heart Disease, Stroke, Lung Cancer, "Other Cancer," and Diabetes. The African American suicide rate was approximately ten per cent higher than the rate for whites. But for homicide, the black to white ratio was a staggering factor of nearly five to one. These data indicate a significant disparity for African Americans among diseases which are for the most part, preventable. It is to be noted that common risk factors shared by these diseases are: smoking, excessive use of alcohol, and substance abuse. Yet the report finds that the identified risk factors are not alone responsible for this disparity. Additionally, it indicates that broader issues such as access to the medical system, the cultural sensitivity of health care providers and perhaps most importantly, the ability to pay for health care services must be addressed. The report concludes that low income imposes a pattern of living which directs available resources to the basic needs of food, clothing, and shelter. It finds that meeting these basic needs on limited income increases the health risks of minority populations. The deleterious results of poverty are indicated in inadequate and overcrowded housing, poor nutritional status, stress, and access to health care services only at times of acute illness.

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47 It seems too, that low income African American seniors are a particularly vulnerable population. Researchers Petchers and Milligan (1988), learned in their intensive study of a primarily African American Cleveland neighborhood, that the cost of Medicare co-payments and deductibles often prevent people from seeking care. These costs also kept many from a regular preventive health maintenance regimen. This older population has special needs. Many had apparently reached senior citizenship after a lifetime of low income. Therefore, when such urgent priorities as prescription drugs and dental care remain outside of programmatic protection, the effects on this population are particularly deleterious. Anthropologist Brett Williams (1992) believes that what has occurred in the last dozen years in the United States is a further disempowerment of the already economically disadvantaged. She writes that recent national macro economic trends such as "industrial reorganization, economic polarization, stagnant and falling wages, soaring household debt, and the increasing concentration of wealth" (167 ) have disproportionately impacted poor people. Further, Williams points out that in much of the social science literature of the last decade, poor people have been portrayed as a homogenized whole that could be stimulated to work if only the right economic punishments and stimulants were applied. This characterization satisfied the requirements

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48 of conservative social policy planners. But it failed to take into account local epistemology. Williams believes that applied anthropologists have a responsibility to engage truly portray the lives in ethnographic research to more of low income populations. Such research among for example, African Americans, would likely reveal that kin and friends are often involved in child rearing. She speculates as well, that younger childbirth tendencies among African Americans may actually be a healthy adaptation. After all, having babies at an earlier age permits the woman to care for other kin when she reaches her middle age. An institution offering medical and social service care could help itself and its community by trying to understand these interesting familial relationships. Due to the information provided by the Primary Health Consortium of Dade County Florida, I have learned of the work of a number of CHCs vis-a-vis their particular neighborhood needs. I shall briefly recount here the work of one such institution. In 1991, the health center, located in north Dade County, provided 97,514 medical visits to 43,775 residents. Their neighborhood particularly is faced with an apparent epidemic of substance abuse. Before 1990, no services existed for substance abusing pregnant women The CHC proceeded to develop a model program for pregnant women and their children. Pregnant women live in and help manage a residential facility. While living there, they receive a variety of

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49 preventive and primary care, as well as social and economic services. Patients participate i n substance abuse counselling, as well as prenatal, and parent education classes. Result s of this program have been promising. The women have a high rate of delivering healthy babies and a low substance abuse recidivism rate. The Florida Cancer Control Advisory Council approved T h e Florida Cancer Pla n (1990) as a meaningful way to intervene to begin to reverse that state's inordinately high cancer rate. Cancer is presently the leading single cause of death a m o n g Floridians aged 25-64. It is also the leadin g cause of death in children up to age fifteen. The disease impacts nearly 60,000 residents each year. The plan indicates that African Americans seem to be at particular risk. In this manner ... Blacks account for 14. 9 percent of Florida's population. Blacks are high risk for tobaccorelated cancers as well as cervical cancer. Indeed, black men are more likely to die from cancer thari any other group in the U S .. The y have a twenty five percent higher incidence of cancer tha n non minority men w i t h more cancers of the lung, esophagu s prostate, stomach, and pancreas. Smoking and c h ewing tobacco are risk factors for lung esophageal, and pancreatic cancer. Major culprits in stomach cancer may be the foods which are high in nitrates and are a significant portion of the diets of blacks. Each of these aspects may be addressed through educatio n and prevention measures which motivate blacks to change behaviors and lifestyle. (State of F lorida D epartment of Health a n d Rehabilitative Services:5) Among the goals and therefore the policy implications of the Florida cancer P lan, the following four a r e predominan t :

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50 a. Provide comprehensive cancer related primary health care services in all counties, to include cancer detection and follow-up services. b. Support a Minorities Outreach Program so that minorities take advantage of existing treatments through clinical trials. c. Support Community Clinical Oncology Programs and further their expansion in the to increase access to clinical trials. d. Support development of community cancer centers in areas lacking access to state of the art care. The Florida Cancer Plan intends to shift state supported resources away from only late stage treatment specialists and towards providers of early detection and education as well as to screening programs for high risk populations. The ultimate goal is to change people's behaviors to decrease their chances of getting cancer. Certainly the prevention of disease is best accomplished when people have an ongoing relationship with a health care provider. In 1970, Robert N. Wilson in The Sociology of Health, spoke of some of the difficulties in achieving just such a helpful association. He said that one of the more difficult hurdles to conquer in building a long standing relationship of trust occurs when the provider and patient are of different cultural backgrounds. Wilson calls for the persistent education of both the provider and patient into each other's culture. To help accomplish this, he urges the emergence of a new type of health worker who would act as an intermediary in helping to clarify information to each partner

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51 in the provider-patient relationship. The author believes that the facilitation of this kind of communication would entail a concentration on preventive health care. Wilson discusses a few common provider-patient misunderstandings. One such difficulty for the male physician is when a woman of a more "traditional" cultural background needs a physical examination. Another situation which lends itself to misinterpretation may occur when numerous family members are present during a patient's treatment sessions. The doctor may regard these relatives as rank intruders. In fact, in many cultures, intimate familial involvement in helping a sick person to get well is common practice. The author believes that effective helping can be achieVed by utilizing health intermediaries who stand between Western medical professionals and an indigenous population. The decision of "government" to effect community health does appear to be a noble endeavour. Yet, as of this writing, there is about the land, a good deal of skepticism about the appropriateness and effectiveness of government help programs. In this regard, I am intrigued by the findings of Mullins et al. (1993), in their study of hot meal delivery to Hillsborough County, Florida senior citizens. Senior Nutrition centers were begun in 1965 with the passage of the Older Americans' Act (OAA). In 1973, Congress passed amendments to the OAA which provided formula grants to states to pay for the establishment of low cost yet nutritious

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52 meal programs for people over age 60. While there have been more recent Congressional amendments, the basis of the program remains unchanged. The researchers divided the county recipients into two groups: one which took a noon hot meal at a senior congregate site, and the other which obtained a similar meal by staff delivery at home. The research team questioned these recipients as to whom or what entity should take primary responsibility for senior citizens. The results for really, both groups are: federal government fifty eight percent, state government forty two percent, local government thirty seven percent, older persons' children twenty eight percent, and older persons themselves nineteen percent. It seems that program recipients at least, feel it is most appropriate for government planners and community helpers to positively impact their lives. While about sixty percent of the clients were living below the poverty line, meal delivery to all recipients was based on ability to pay. With this in mind, there was repqrted difference between the two groups in their assessment of their own economic vulnerability. While twenty two percent of the eat-at-home group felt they did not have the funds to make ends meet, only ten percent of the congregate meal clients felt that way. Similarly, three-quarters of the home delivery recipients compared to fifty four percent of the congregate

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53 participants, felt that not having enough money to live on was a somewhat or very serious personal problem. Perhaps not surprisingly, there was also a difference in the two groups' experience of loneliness. The comparative group results were thirty eight percent for the home delivery clients versus only twenty two percent for congregate partakers. Also thirty six percent of the congregate clients visited each other in their homes. I would suggest that the aforementioned results indicate that the congregate center program has a likely nurturing effect on its clients' sense of personal well being. The goals of the county program appear to have been reached. First, low (or no) cost nutritious meals are being delivered to senior citizens. Secondly, the delivery of meals to those most vulnerable (low income, those in poor health, the socially isolated) is being accomplished. Further, minority populations are more than proportionally represented. It seems that this federal program is achieving a helpful community intervention. Among other proof, there are waiting lists for the congregate senior sites. This is true for both the dining capability as well as the often accompanying social and social service oriented programs. The intervention appears to be both welcomed and needed. In "Health Care of the Poor Elderly: Supplementing Medicare," (1985) Marc L. Berk and Gail R. Wilensky provide additional evidence that government programs can beneficially

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54 effect health care deli very. Using data tabulated by the National Medical Care Expenditure Survey (1977), they sought to learn of the utilization of health services by the elderly poor and near poor by means of their type of insurance coverage. The results are hereby presented: Table 2. Utilization of Health Services by Elderly Poor and Near Poor (Mean)-Physician Visits Prescription Drugs % Hospital Stay Medicare Only 4.2 8.7 18.0 Medicare +Medicaid 7.0 15.3 23.3 Private + other 6.5 12.2 2.0 (Berk and Wilensky 1985:313) For those low income seniors who had both Medicare and Medicaid availability, the mean health care accessibility percentages were the most accommodating of this group. They had more annual physician visits, were able to take more advantage of prescription drugs, and were able to avail themselves of more comprehensive hospital stays. Those able to afford private insurance in addition to a government plan (likely Medicare), fell into the middle usage group. Those seniors who were forced to rely on Medicare only had the least systemic contact.

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55 Parenthetically, the authors found that only 5.4 percent of elderly poor non whites were able to afford private insurance. They note too, that many Medicare costs must be paid out of pocket. These charges include Part A and Part B Medicare deductibles, as well as the difference between what Medicare is willing to pay the physician per service rendered and the actual doctor's fee. Those who must rely exclusively on Medicare, incur substantial out-of-pocket costs, even though they use much fewer services than those who also have Medicaid coverage or private insurance protection. It is appropriate here to remind the reader that many important services which disproportionately impact seniors are not covered by Medicare. Among the notable non-covered services are the following: dental care, prescription drugs, eyeglasses, as well as other types of medical equipment and supplies. The authors demonstrate that for many low income seniors, Medicare plus Medicaid coverage affords this population more frequent systemic health care intervention. The programs do make a difference. It seems.likely too, that Medicare-only coverage is better than no coverage at all. A special report prepared by the National Association of Community Health Centers entitled Lives In The Balance: A National, State, and county Profile of America's Medically Underserved (1992), offers a poignant profile of this country's medically vulnerable. The study uses two

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56 specifically designed measures of "under service." The first is a composite measure of the overall health of each u.s. county and is derived from a range of county-level health and demographic indicators commonly used by the federal government to measure health and well being. The second measure identifies the number of U.S. county residents who, regardless of personal health condition, live in areas with an inadequate supply of primary care physicians and thus can be considered underserved. The study finds that the overwhelming majority (40.5 million medically underserved Americans) are not receiving care as measured by their significantly diminished overall health status, rather than as a result of living in areas with an-actual physician supply shortage. It seems that the largest number of underserved persons are found in large metropolitan counties. Ironically, many of these counties feature an adequate number of medical providers. Yet, they appear to be inaccessible to large numbers of low income people. Lack of health insurance (for 3 7 million people), provider refusal to participate in Medicaid, and the inaffordability of uncovered services for low income Medicare beneficiaries, are all factors in making local doctors inaccessible to millions of at-risk persons. The study finds too, that the problem is made more difficult by cultural and language barriers as well as inaccessible physician hours and locations.

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57 In 1990, the U.S. census reported a domestic population of nearly a quarter-of-a-billion people. In that year, according to this special report, 42.7 million Americans were classified as "medically underserved." Of these, nearly ninety five percent are underserved by health measures. Only a little over five percent, are so designated by area physician shortage. Americans who are medically underserved span all ages and races and come from all parts of the country. Here are a few revealing population highlights ... -14.2 million (33.2 percent) are children under age eighteen, and 5.7 million (13.3 percent) are children under age six. -9.1 million (21.2 percent) are women of childbearing age eighteen to forty four. -10.1 million (23.6 percent) are elderly or disabled Medicare beneficiaries. As of this writing, our country's elected officials are engaged in debate about the future of health care delivery. For now, two of the agreed upon goals seem to be universal coverage which can never be taken away, and the need for systemic cost containment. Yet the report finds that without a community accessible "welcoming entry point" to the health care system for low income people, our shared national goals will be difficult to realize. Jack H. Geiger M.D., was a structural and philosophical architect of American CHCs. He envisioned the institutions as

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58 more than medical centers for low income people. Geiger articulated a broader goal of social and political change which, he hoped, would effect the determinants of health status that existed in the economic and social order. He believed that health care services should be deliberately used as a "point of entry" for such broad social change. These ideas fueled the growth of the early CHCs. The planners of the 1960's and early 1970's thought of themselves as part of a liberal reform oriented "community health care movement." They thought that real change in service delivery could not be accomplished by merely increasing government funding. In Dr. Geiger's own words ... The mere provision of tokens for the turnstiles of the existing medical care system would not lead to equity, so long as that system was remote, hospital centered, professionally controlled fragmented, middle class in its orientation, and unaware of (or unresponsive to) the social, physical and biological environments in which both urban and rural poor lived. A new kind of institution, differently organized, locally based, and focused on primary care, would do better (1984:16). Health problems were viewed by the policy initiators as socioeconomic as well as biological in origin. Medical care was as much social process as technical commodity. Yet the goal was more than an alternative medical system for low income people. It was genuinely hoped that these new progressive institutions would lead to fundamentally more democratic changes in the entirety of American society.

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59 The need was viewed as more than the dissemination of medical assistance to "passive" low income people. Instead, the goal was the active involvement of local populations in ways which would change their knowledge, attitudes, and motivation. The central focus was to be on community health care. The ultimate goal was broad ranging community empowerment. We have previously described how the more conservative American Administrations have adversely effected CHCs. Yet, portions of the original model are today quite dynamic. In many centers, outreach workers are recruited from target populations. They have time and again demonstrated power of "nonprofessional" locally trained employees in positively effecting health care outcome. In many centers too, physicians, social workers, dentists, family health workers, nurse practitioners, public health nurses, community organizers, and health educators are working together as health care teams. The CHCs have also been instrumental in teaching local residents valuable skills. The centers.have helped many to achieve careers as sanitarians, physical therapists, medical record librarians, X-ray technicians, medical assistants, computer operators, and office managers. Geiger believes that the nation's medical system has been modified. Yet, he says the basic structure has not changed. In his opinion, it remains hospital centered, technology oriented, and entrepreneurial, and if anything, more corporate

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60 than when the CHC movement began. I think, however, it is fair to say that CHCs do at least make strides in the direction of low income people's health care access. This proposition is tested by Louise M. Okada and Thomas T. H. Wan (1980). These researchers designated five baseline and follow up low income neighborhoods located throughout the United States to examine the effectiveness of CHCs and Medicaid on prospective patient use of health services. To begin, the authors found that upon patient query, primary care given at hospital clinics was often fragmented and treatment oriented. Further, patients often had to travel long distances to receive care. Results showing the usage difference between the two trial years of 1969 and 1975 are instructive. Table 3 The Effectiveness of CHCs and Medicaid on Prospective Low Income Patient Use of Health Services Usual Source of Care Baseline Survey Follow up Survey Private Physician 43 34 Hospital Clinic 44 31 CHC 2 23 Other 2 3 None or Not Stated 10 9 Total 101 100 (Okada and Wan 1980:522)

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61 The bulk of clients for CHCs came mostly from hospital clinics and persons who previously had no regular source of health care. As a result of the implementation of Medicaid, Medicare, and the growth of CHCs, it appears that some equity in access to health care for low income individuals has been achieved. Between 1969 and 1975, the annual physician visit rate among the tested populations rose from 3. 6 per person to 4 .1. Acknowledging this, it is also true that the gap in annual physician visit rates actually grew between these neighborhoods and the rest of the country Parenthetically, whites in and out of the tested areas saw physicians more frequently than African Americans. This gap is greater within the five observed low income neighborhoods. The lowest physician usage was by African American children. It was learned that CHCs made an important contribution to physician utilization by providing services to persons without health insurance. One quarter of persons with no health insurance coverage reported a community health center as a usual care source. Significantly, this group had more frequent physician visits than others without health insurance who sought care elsewhere. The survey also found that many who had used the centers would likely have gone to hospital clinics for care, thereby resulting in lower physician use rate.

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62 The researchers learned that having available financing for the health care needs of low income people offers some help. For example, annual physician visit rates for people covered by Medicaid or Medicare were fifteen percent higher than for people covered by private insurance. But we learned as well, that having available financing alone, may not necessarily of itself produce health visit equity. The authors found ... The low physician use among children, blacks, and persons without chronic limitation is evidence that, for some groups, the perceived need for physician services is defined at a relatively low level. The greatly increased access to health care through CHCs and Medicaid did not raise the level of physician use in these low income areas to comparable national levels. The fact that pockets of underutilization persisted in spite of increased access to physician services indicates that financing and improved access to health services are not the only answer to problems of underutilization (527). Nevertheless, the authors found that CHCs are reaching the subsets of the population for which they were planned. These include low income people and African Americans. Additionally, they attract a disproportionately high number of children among the age groups. The CHCs in the five studied neighborhoods, contributed to increased access to care for the population. It is also to be recognized that travel time to source of care was considerably shortened by the generally centralized location o f neighborhood CHCs Furthermore, CHCs were successful in

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63 lowering hospital admissions when compared to private physicians and hospital clinics. Daniel S Blumenthal et. al. (1993) suggest that there needs to be more of a change in health care delivery than simply making it popularly affordable. The authors ask policy makers to consider cultural, language, and geographic barriers to care in their formulations of an emerging system of more efficient delivery. Moreover, they say large and vulnerable population segments suffer disproportionately from health problems not adequately addressed by the present system of health care deli very. They suggest that such problems as teenage pregnancy, AIDS, injury, and drug or alcohol abuse could best be cared for by what for now are less traditional health care outlets. The authors advocate the expansion of CHCs for neighborhoods featuring health care vulnerable populations. In their view, these organizations are cost effective. Further, it is believed that with the growth of CHCs, provider distribution would be improved. These institutions (as presently configured) could combine personal health services with health care promotion. Among large numbers of low income Americans, perceived need for health care is more closely defined as need for illness care while more affluent groups may explain health services needs in terms of both illness and preventive care. In a book called Access to Community Health Care (1992), we

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64 get a more statistical view of the help CHCs are offering. We also learn about the length and breadth of the problem of delivering quality health care to low income Americans. We learn, for example, that while Medicaid covered sixty percent of the nation's non-elderly poor in 1980, today only 47.2 percent of the non-elderly poor are currently receiving this program's protection. These figures are disturbing but are made even more so when we realize that the number of Americans living in poverty has grown by approximately fiveand-a-half-million since 1980. The text reveals that there is a very real human (and financial) price to pay for this country's checkerboard like access to health care. For example, the United States today spends more per capita on health care services than any other industrialized nation. Yet in 1989, it ranked 20th worldwide in infant mortality. Among African American infants, the 1988 mortality rate was 17.6 deaths per 1000 live births which was more than twice the white infant rate. The inability to pay for out-of-pocket expenses and care for services not covered by Medicare today plagues this nation's low-income elderly. For the most part, this constituency does not have Medicare supplementary insurance. Therefore, when it comes to often needed (and not Medicare covered) items such as prescription drugs or dental care, these seniors are in jeopardy.

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65 I am drawn to statistics which reveal health center patient demographic information. Using combined data from both community and migrant health centers, we learn that in 1991, C/MHC's provided primary and preventive care to over six million people. Over sixty percent of these recipients were members of minority groups. 'Minorities make up over seventy percent of urban center clients. A full ethnic breakout of those who sought help in 1991 is as follows ... Table 4. Ethnicity of Community and Migrant Health Center Clients African American/Black ................... 37.0 % White/Non-Hispanic ....................... HispanicjLatino .......................... 27.2% Asian/Pacific Islander .................... 3. 2 % Other ..................................... 1 9 % Native American ........................... 0.8% (National Association of Community Health Centers 1992:7) Nearly thirty percent of C/MHC clients are unemployed. Seven-and-a-half-percent are pregnant women. Almost five percent are homeless. Approximately two-and-a-half-percent have tested HIV-positive. Again, according to ACCESS TO COMMUNITY HEALTH CARE, the medically underserved population in the United States at the end of 1991 was 42,763,620. Of these, fifteen percent were

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66 served by C/MHC's. That year, the uninsured population totaled nearly thirty-four million. The uninsured population whose earnings were below two hundred percent of the established federal poverty level was over 20.5 The subject of medical health insurance represents the fulcrum of contemporary health care discussion. Therefore, it is helpful to be aware of the health insurance status of C/MHC clients. For example, forty three percent are publicly insured by either Medicaid or Medicare. An exactly equal number of recipients have no medical insurance coverage. Fourteen percent of health center clients are privately insured. Community health centers seem to be offering to populations with previously limited access to preventive health care. In A Health Center Reaches Out To Neighborhood Children and Schools (1991), I learned of one CHC which tried to ameliorate a crisis of health care (at least) among neighborhood children. It seems that again by necessity, in many of the homes in this studied south Florida neighborhood, preventive health care has to take a back seat to. the urgencies of food, shelter, and clothing. The CHC decided to collaborate with local schools to effect a health care intervention. Their working hypothesis was:

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67 Identifying health problems and changing lifestyles will be most effective if started with young children. Early exposure to health care professionals, intervention and followup on health problems will result in improved health, decreased absenteeism, and enhancement of the children's learning process (Primary Health Care Consortium of Dade County Florida, Inc. 1991:4). The idea was to build a permanent base upon which children may conceive of and rededicate themselves to a permanent healthy lifestyle. Today, we see in many communities, a significant rise in single family households and families with two working parents. The situation with many contemporary families makes the involvement of health professionals in school programs a timely consideration. In particular, it was thought that school health screening, referrals, and follow-up mechanisms to help children obtain appropriate medical assistance would prove beneficial. In interacting with the community public schools, the CHC professionals established four goals ... 1. Provide a health care team, including a board eligiblejcertified pediatrician, to screen children who are not under the care of a private physician. 2. Identify and refer those with health problems which require additional medical, specialty, or social service follow-up.

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68 3. Promote health education within this screening process for children, parents, and teachers. This should reduce absenteeism resulting from health problems and thus enhance the child's learning capacity in the classroom. 4. Provide strong dedicated health care professionals as role models for future development of the children (Primary Health Care Consortium of Dade County Florida, Inc. 1991:9). Critical to the program's success was the early involvement of the school administrators. Also, at some schools, the program was to be assisted by the school nurse and parent outreach specialists. When the design was complete, the plan was endorsed by the Department of Public Health. The Family Health Team were frequent visitors to the four local elementary schools. The children were screened in small groups to minimize the disruption of the educational proces. It was viewed as an important part of this program, that screening would be limited to children who had returned a signed parental consent form. As the program evolved, teachers noted specific problems and referred their students to the pediatrician. After six months, the program was evaluated and helpful teacher and parent suggestions were included. It was thought

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69 that for both children and parents, there should be more incorporation of health education into the screening process. Also when appropriate, there should be more collaboration with physical education departments to develop programs which combat the problem of childhood obesity. There was to be developed a special focus on children who had been designated as having a learning disability. Also, after school hour parentjchild educational sessions were to be created so that working parents could attend and the child's educational disruption would be minimal. The program is on-going. Systemic Cost Effectiveness It is timely to examine the cost effectiveness of the present means of delivering medical care in the United States. According to Citizens Fund (1990), a not-for-profit, nonpartisan consumer research organization, the present system of delivering health care to America's citizens is terribly inefficient and inequitable. The organization contends that the inefficiency begins with the private health insurance industry. The group found that for every dollar the commercial insurance industry paid in claims in 1988, they spent 3 3.5 cents for administrative costs, marketing, and other overhead expenses. These findings indicate that not including profits, the industry spent fourteen times as much on administration,

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70 overhead, and marketing per dollar of claims paid as did the government run Medicare system. Unfortunately, these aforementioned costs have increased even faster than the fast rising health costs themselves. Today, our insurance companies find it necessary to spend billions of dollars competing with each other to insure the healthiest among us. In order to lower its risks of paying claims and increasing its chances of earning profits, each insurance company spends vast amounts of money on underwriting, marketing, and perhaps most noticeably, denying claims. Most companies spend great sums of money on administrative staff whose job it is to their deny their clients' claims. Incredibly, this report finds that the commercial insurance industry spends more annually to deny people coverage, than it would cost to provide everyone with major medical protection. The United States spent over $600 billion on health care in 1989. Per capita health care spending was $2,051 compared with an average of only $1,069 for America's international competitors (Japan, West Germany, France, the United Kingdom, and Canada). Yet among these same competitors, the U.S. ranks last on measures of infant mortality and child mortality. The United States leads only the United Kingdom in the measure of life expectancy. The present system is even costly to those who can afford major medical coverage. For example, after having to meet an

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71 annual deductible, the typical policy requires that twenty percent of medical costs (co-payments) must be borne by the policy purchaser. And today's premiums it is widely agreed, are rather dear. Also, many people report experiencing difficulty getting claims paid and bills corrected. Individual policy holders have traditionally paid much higher premiums than people who are able to obtain group health insurance. Individual policy holders might typically be employees of companies which do not provide insurance, the self employed, part-time employees, and sometimes, the unemployed. Of course, overhead expenses are far higher for the insurance companies to cover an individual policy holder than for a group. The systemic inefficiencies are also considerable. For example, each of the 1,500 companies underwriting policies (and many have several policy types) have their own forms and codes which doctors and hospitals must learn to manipulate. This often requires doctors to hire staff specifically trained in medical insurance administration. It also requires hospitals to hire considerable staff for similar purpose. Today, administrative expenses consume eighteen percent of an average American hospital's budget. Business too, must bear these costs. Many businesses have had to hire similar health insurance staff. Many larger companies have had to hire expensive health care benefits consultants to help find the best policies in a very dynamic

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72 insurance environment. Parenthetically, the General Accounting Office reports that roughly one-third of small businesses in this country leave their insurance company each year or are not renewed. Since at least the beginning of the 1980's, "government programs" have been much maligned for their spending inefficiencies. Yet, in the Citizens Fund (1990) report, we learn that administrative and overhead costs for Medicare are only 2.3 percent of program claims. How much a provider spends to give a dollar' s worth of coverage is called the expense to claims ratio. The efficiencies or lack there of, of the private insurance industry versus the costs to Medicare are illustrated below. Table 5 Estimated Insurance Expenses for the United States Expense Individual Family to Coverage Policy Claim Ratio Estimated Expenses Commercial Insurers 26.9% $316 $675 Medicare 2 .3% $ 27 $ 58 (Citizens Fund 1990:17) In the ensuing health care policy debate, we hear a great deal about government inefficiency. In many cases the claim is valid. Yet, program defenders are often asked to name a

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73 single government program that is run efficiently. Ironically, the answer may be as close as the present health care system. Though Medicare is annually attacked and its benefits in relation to medical expenses are made to lag, the program does deliver efficient help. In the television documentary, America's Health Care Going Broke In Style (1992), it was reported that a typical family practice physician would spend nearly half of hisjher day negotiating the "hassle factor." The term refers to the mountain of paper work and phone calls the doctor must personally oversee just to get paid. Also, it was said that the threat of malpractice makes for over protective medicine. Features of same are unnecessary medical procedures and, of course, more paper work. Further, this television program noted that typically across this country, insured hospital patients pay thirty percent above what their typical rate would be in order to make up for non-paying patients. I note that most of the non payers are working people. When they entered the hospital, most thought they were either. insurance protected or that they could personally afford the hospital bills. But with today's costs being what they are, many patients are simply financially overwhelmed. It is helpful to consider "what drives costs" in today's health care deli very system. The answer seems to be, just about everything. contemporary health care delivery expenses

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74 are at least a triangular problem. We have already discussed the private insurance industry's contribution But many physicians are charging what the market will bear. And their "market," with the help of private insul;'ance third payers, pays dearly. Yet, doctors are forced to pay exorbitant rates for malpractice insurance. Unfortunately, most of us know of the high rates charged by hospitals. We know too, that medical technology is expensive, and that in some urban areas, neighboring hospitals have duplicate machines. In the NBC report, I learned that many hospitals complain that in the case of senior citizens, Medicare only reimburses them at fifty percent of cost. This must obviously be difficult to absorb. It must be particularly hard for an institution that is forced to engage a large staff for the sole purpose of negotiating the paperwork produced by 1,500 major medical insurance carriers. This then, is an appropriate juncture to discuss what appears to be an emerging health care policy consensus. The system is "broke for a large number of citizens and. the Clinton Administration seems to have offered the most complete prescription for a future health care delivery policy. To place the political environment in perspective, we do know that it is not the poor who are driving the health care debate. Richard L. Berke (1993) reports that the health care agenda is being driven by middle class fear. Or in the words of political economist uwe E. Reinhardt, "I don't think it's

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75 compassion that drives this ... the middle class feels in the middle of a swamp named 'uninsurance', and it is really that fear of losing insurance that the President is harvesting." I do wonder if Stanley Brody would call this perception "the fourth catastrophe?" Indeed, baby boomers are moving out of their maximum wellness years. They are not yet old enough for Medicare protection and generally not poor enough for Medicaid. Therefore, there presently exists a rare American political opportunity to profoundly change the system of health care delivery. The time is the more exceptional when we consider that major health care reform had been considered by many Presidents. Their efforts were not successful because their ideas lacked broad based support. For example, Franklin Roosevelt at one time hoped to imitate all of the post-war allies in bringing about universal health care. But, he surmised that such a program would sink his more limited Social Security Act. Harry S. Truman, the first President to call for guaranteed medical coverage lamented in his memoirs: "I usually find that those who are loudest in protesting against medical help by the Federal Government are those who do not need help." Let it also be said that Harry S. Truman' s "really good friend," Richard M. Nixon when he was Chief Executive, proposed a plan not very dissimilar from that of the Clinton

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76 Administration. His plan was presented at about the time of the Watergate crises and as we know, neither Mr. Nixon's plan, nor Mr. Nixon himself politically survived. September, 1993, was the "magic moment" in which President Clinton unveiled his health care delivery package. Mike Oliver (1993) reports that the program is far reaching and multi-faceted. I present the fundamental principals and regulations ... Who is covered: All legal residents of the United States would be guaranteed some form of health insurance. All would be entitled to a minimum set of benefits which could never be taken away, regardless of illness, job changes, or unemployment. What you would get: Legal residents would be entitled to coverage for hospital care, emergency services, hospice and home health care, visits to doctors and other health professionals, pregnancy-related services, ambulances, outpatient laboratory tests, prescription drugs and outpatient rehabilitative services. Reimbursement for dental and eye care would be limited at first

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77 b u t plans call for expanded coverage by the year 2000. Reimbursement for mental-health and substanceabuse services would also be initially limited. Up to sixty days treatment would be covered early o n but the plan is expected to permit ninety days of coverage by 2000. Senior citizens would gain a new prescription drug Medicare benefit. They would pay for twenty five their Part deductible percent of the program through B premium, plus a $250 annual and then twenty per cent of a prescription's cost up to a yearly maximum of one thousand dollars. Further, a new long term care program would be provided for the elderly, chronically ill and severely disabled, with federal reimbursement for nursing home and home based care. Free preventive care would be offered, based on a schedule set by the government. Included: children's school immunizations, annual physicals, and screening procedures, such as

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78 mammogram, Pap smears, pre-natal and wellbaby care and cholesterol checks. How the plan will work: All legal residents would be issued a national health identification card which would guarantee them access to medical service. Most people would then be purchasing their health insurance through a regional alliance which would pool its members purchasing power to negotiate lower premiums from insurance companies and hopefully higher quality care from hospitals, doctors, and other medical providers. The alliance would be able to offer a variety of health plans to its members. States would have the option of establishing a single-payer system instead of managed competition. Under everyone would be a single-payer system, issued a insurance card. Patients could government go to the provider of their choice, and all payments would be made by the government. Most private health insurance would be eliminated except if patients wanted to insure themselves for

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79 seeming extras such as cosmetic surgery. The government would set prices for care. Senior citizens would remain in the federal government's Medicare insurance program for now, but those who turn 65 years old after the regional alliances are formed, would elect to stay with their alliance plan. Poor people, currently eligible for Medicaid, would be transferred to the regional alliances and receive the standard package of benefits. The person's premium, based on one's ability to pay, would be subsidized by the government. Paying the bill: Under the plan, the premium for the government's standard insurance package would average $1,800 a year for individuals and $2,400 for families. Businesses would be required to pay eighty percent of that standard premium for their employees coverage, but they would have the option of paying more as a fringe benefit. Companies with fewer than 50 employees or with many low wage workers would be eligible for premium subsidies from the government.

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80 Employees would be required to pay the difference between their employer's contribution and the full cost of the health plan they select. Under the basic fee-for-service plan, which permits a patient to use their physician of choice, the consumer would pay an annual deductible ($200 for an individual or $400 for a family) and twenty percent of all costs after that (up to a maximum of $1,500 a year for individuals and $3,000 a year for families). Under the basic managed care plan, patients would be limited to plan approved doctors, but they would pay no deductible and only $10 per office visit. Self employed indi victuals could get a government subsidy to help pay their insurance premium, based on income. If a person is unemployed, they would have their premiums paid by a government fund.

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81 Cost Control: A National Health Board would oversee the system and set annual national health care budgets. The goal of the plan is to limit annual increases in he?lth care spending by 1999 to the general rate of inflation. If managed competition among insurers and medical providers did not slow the growth in spending, the board would be empowered to limit insurance companies' premium increases, forcing the health plans to spend less. Government would also commit to slow the growth in its budgets for Medicaid by limiting the yearly the reimbursements it pays hospitals. Medicare and increases in doctors and The cost of processing medical claims and other paperwork would be reduced by the government's introduction of a single standard insurance form. All consumers, insurers, and health care providers would be required to use this new document.

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82 Quality Control: The National Health Board would establish a system for monitoring the performance of doctors and hospitals. It would also be charged with developing a measuring device to examine the overall quality of medical care. Further, incentives would be imposed on medical school residency programs to encourage more doctors-in-training to become primary care physicians instead of high-priced specialists. Several states are presently about the business of formulating their own health care delivery systems. One such example is The Florida Health Security Plan. As described by Diane Hirth (1994), the plan of the current Chiles Administration would prune basic health insurance costs for all Florida residents. Part of the plan also involves subsidizing working people who do not get coverage through their employers and who cannot afford the full premium. The Governor is presently challenging the Federal Government to give the state plan the go-ahead. If the plan is permitted, it is believed that premiums would be about $111 a month for individuals and $331 a month for families for basic coverage purchased through regional "community health purchasing alliances." Employers and employees would split the cost but unlike the rules of the Federal plan, no party would be forced to participate.

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83 It is anticipated, that subsidies for individuals who earn $17,425 or less a year, or families of four that earn $35,875 or less a year, could drive the cost down further-to as low as $6 a month for the insured person. Even people with severe or chronic illnesses would qualify for any of these rates once they get past a likely pre-existing condition twoyear time limitation. Approximately 1.1 million state residents or nearly half the estimated 2. 5 million uninsured would be eligible to receive subsidized health insurance from The Health Security Plan. To qualify, one would have to prove U.S. citizenship and Florida residency and provide income verification. National and state business groups have hailed the Chiles approach and comparedit favorably with the Clinton plan. One reason for said enthusiasm may be that again, the state plan does not mandate employer participation. Florida intends to pay for health care delivery by reallocating existing funds. It will not raise taxes. To proceed, the state will require a federal waiver to shift federal and state funds currently spent on Medicaid. Florida also plans to redirect dollars now used to subsidize hospital charity care and uninsured patients not eligible for Medicaid. Ultimately, funding could be provided in the following proportions: federal dollars-fifty percent, state participation thirty two percent, employers (if so elected) nine percent, and employees nine percent.

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84 Under the proposed plan, essentials such as hospital, emergency and diagnostic care would be covered. Preventive care for adults and even more extensively for children would be available at low or no cost. Also, and this is important considering the large proportion of seniors in Florida, most prescription drugs would be covered under the plan. As of this writing, concern is being voiced about high deductible and copayments required for some services. It is into this emerging political health care environment that I choose to examine just how cost effective community health centers are. According to the National Association of Community Health Center's The Future of Community Health ( 1991), CHCs have been providing care at costs which are substantially below other settings. For example, laboratory, medical, x-ray, and pharmacy costs are about two-thirds the national average. These cost savings result in part from the fact that patients who do not use health centers, go for longer periods without care and thus require higher intensity care when they ultimately use services. When health center patient Medicaid costs are compared to non-CHC medicaid costs, the efficiency of health centers becomes apparent. For example, patient encounter costs for Medicaid patients who use CHCs are only fifty eight percent of those incurred when Medicaid beneficiaries use hospital outpatient departments.

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85 Furthermore, CHCs systemically reduce the cost of hospital care. Hospital admission rates for center users are found to be lower than for those persons served by either hospital outpatient departments or private physicians. Moreover, the length of stay for hospital patients served by health centers has been shown to be considerably shorter than for patients seen by hospital outpatient departments or by private physicians. Hospital days per year per patient amounted to .4 days for CHC patients, .6 days for physicians' patients, and .8 days for patients of outpatient departments. Community health centers have proved to be money savers for state Medicaid programs. The health centers have been shown to reduce by forty percent, Medicaid payments perperson-per-year. Among AFDC-eligible Medicaid recipients, ageadjusted hospital admission rates have been shown to be less than one-half the rate for nonusers. Significantly, the value of reduced inpatient hospital expenditures has been shown to amount to one-and-one-half times more than the total annual federal appropriation for the CHC program. It may be noticed that with these savings in mind, CHCs might be a good fit in any emerging version of health care delivery. Or, as well stated in a book entitled and published by the Primary Health Care Consortium of Dade County Florida, Inc. "in an era where medical demand far exceeds society's ability to pay for it, local decision making is an effective tool to set priorities and make those

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86 difficult decisions that ration care" (Primary Health care Consortium of Dade County Florida 1992:3). Recently, I have been informed by an article (Yang, Shah, Watson, and Mankad: 1995) comparing systemic costs of comprehensive versus episodic health care for Sickle Cell patients. In this study, nearly 400 afflicted people were surveyed at the University of South Alabama Medical Center. The most important question concerned whether patients had previously been treated at specifically disease oriented Comprehensive Health Care Clinics. The survey results demonstrated that 33.5 percent of patients seen at the University of South Alabama Medical Center had not attended the clinics. These same patients though, accounted for 71.4 percent of Sickle Cell visits to the emergency room and 42.3 percent of inpatient admissions. The author's found that patients enrolled in the Sickle Cell clinics were responsible for significantly smaller health care costs. Speaking to issues of national health care policy, the authors suggest that on superficial analysis, social support of a community program may appear to be more expensive than a single physician providing care in an emergency room or a hospital. However, this study demonstrates that health care in the emergency room or in inpatient units is more costly than health care in the special outpatient clinics. The researchers also say that limits on outpatient visits,

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87 services of multidisciplinary teams, preventive care, and psychosocial support may be counterproductive to a cost effective system of health care delivery as such decisions would result in increased overall expenditure. Ethnically Sensitive and Neighborhood Wise Part of a definition of "quality health care," must lead health care providers toward an understanding of the mores and health habits of their primary service area population. To best serve their respective communities, providers must be aware of such service delivery variables as: convenient (and culturally acceptable) hours of operation, transportation facility, provider time spent with patients, and staff appearance and comportment. Further, we know that community health care is a dynamic which bears constant appraisal. For example, recently we have witnessed the rise in the childhood ingestion of lead based paint, the public acknowledgement of domestic violence as a problem where social agencies should intervene, the reappearance of Tuberculosis, and the scourge of AIDS. All are obvious conditions which must move local healers to be knowledgeable, compassionate, flexible, and intellectually curious.

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88 In "Access to Health Care for Hispanics ( 1991) Eli Ginzburg discusses the impediments of "Hispanic Americans in their ability to find convenient health care. It is important to first designate the Hispanic groups discussion. In the United States today, the u.s. Census Bureau designates Hispanic people in the following manner: Mexican Americans (sixty two percent), Puerto Ricans (thirteen percent), Cubans (five percent), and Spanish-Mexican-Indian population of the Southwest (eight percent). The agency classifies a first generation person from one of the aforementioned countries as "Hispanic," though I wonder how a second generation naturalized U.S. citizen would be classified. The author notes that people of lower income frequently have less of an opportunity to find convenient and affordable health care. He noted that lack of educational attainment is frequently associated with lower income positions. According to his census data, seventy seven percent of the white population finished high school as contrasted with forty four percent of Mexican Americans, fifty three percent for people of Puerto Rican descent, and sixty one percent for ex patriot Cubans. Ginzburg found that many Hispanics are poorly positioned to access the health care system by virtue of below average family income, above average rates of employment where no health care insurance is provided, and sizable numbers who live in states (Texas and Florida) which by design, force low

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89 Medicaid enrollment. The author also relates that Hispanics' disproportionate representation in the lower income strata points to an above average need for health care services because of the association of lower socioeconomic status with poor health status. It seems that Mexican Americans and Puerto Ricans have a disproportionately high rate of incidence (up to three times) of type II diabetes as compared with the general American population. Moreover, this disease strikes a younger age group and often leads to complications that have been attributed in part to the difficulties encountered in obtaining adequate health care. It also seems that nearly one third of Mexican American and Puerto Rican women are obese. Other data point to differentially high rates of cancer of the cervix among Hispanic women, which may be caused in part, by their inadequate access to and use of preventive services. Suggesting more difficulty, we know that the designated Hispanic population in the United States is ten percent and rising while the percentage of Hispanic physicians is presently only 5. 4 percent. The author suggests remedial measures to improve the health status of the Hispanic population. He believes that intensive health education programs conducted by community groups, and particularly the preparation and dissemination of preventive health materials in Spanish, will begin to close the gap between the needs of

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90 Hispanic health care users and the availability of Hispanic health care providers. He also suggests systemic health care changes which he believes would particularly improve Hispanic people's health care access. He would avor, at least in the short term, an extension of Medicaid coverage by mandating or permitting the states to liberalize eligibility requirements for women and children. For the ong term, he supports a policy of national health One of his policy features would mandate all employers to provide employees with major medical insurance coverage. In his view, "since a high proportion of Hispanics lack adequate, if any insurance, such efforts ... should facilitate their access to health care and improve the level of care they obtain."Ginzburg believes a system of national health insurance would be responsive to many of the health and medical needs of the Hispanic population. In CANCER FACTS & FIGURES-1993, The American Cancer Society presents a telling table of cancer survival rates. The table is an extrapolation from their statistical data. Given the cancer prevention and detection information available today, we may say that the cancer survival rates of these two groups could likely be prolonged by annual checkups. Further, helpful dietary knowledge could also prove beneficial. so, too, could appropriately placed neighborhood warnings on the dangers of cigarettes, cigars, and smokeless

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91 tobacco. Most importantly, we believe that early detection is the key cancer survival variable. Table 6. Trends in Cancer Survival Rates by Race (1983-1988) (Relative 5-year survival rates) White Black Colon 59 48 Rectum 57 46 Lung and Bronchus 13 11 Melanoma (skin) 83 68 Female Bre a s t 79 62 Cervix uteri 68 55 Corpu s uteri 84 54 Ovary 39 37 P rostate 78 63 Testis 93 84 Urinary/bladder 79 59 Kidney & renal pelvis 55 53 Brain & nervous system 25 32 Leukemia 38 29 (American Cancer Society 1993:17) The west-central coast of Florida is the primary metropolitan area in which I have conducted m y graduate

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92 studies. The effected Chambers of Commerce wou l d have you recognize the area as "Tampa Bay." The bay area is principally comprised of Hillsborough and Pinellas counties. Tampa is the largest city in Hillsborough County. St. Petersburg and Clearwater are the largest Pinellas cities. I think it interesting at this juncture, to compare the adjoining counties for differences in disease indications and to do so using such variables as: same sex v. heterosexual contact (i.e., for HIV), sex, and racejethnicity. The data presented is culled from a state report entitled, Florida: Aids and Other Sexually Transmitted Diseases-1991 Annual Report. Table 7. Proportion of Cumulative Adult AIDS Cases, Reported Through 1991 (N-1,047) By Exposure Category Hillsborough Pinellas Male to Male 3 8 % 69% Heterosexual 47% 6 % Injection-Drugs 8 % 15% other 7 % 10% (Florida, The State of 1991:44,64)

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9 3 I notice the large discrepancy between the adjoining counties in terms of the male to male and heterosexual contact and adult AIDS cases. Table 8. A Two-County Comparison of Proportion of Cumulative Adult AIDS Cases, Through 1991 By RacejEthnicity Hillsborough Pinellas White 65% 78% Black 22% 20% Hispanic 12% 2% other 1 % (N=1,047) (Florida, The State of 1991:44,64) I notice that 1n each county, African Americans do have disproportionately higher cumulativ e adult AIDS case indices than would be expected for a population in each county of about twelve percent. I also notice a difference in the comparison of the two-county Hispanic populations. Happily, the incidence of Syphilis infection has been declining in each adjoining county. For example, in Hillsborough, the number of reported cases in 1986 was 157. The number peaked in 1989 at an alarming 629. But in both 1990

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94 and 1991 there was a steep decline with the later years' number of reported cases at 138. Similarly in Pinellas County, the 1989 statistic was 130. It too peaked in 1989 at 465. But in 1990 and 1991, the trend has also been down with the latter year's number of reported cases at 220. Table 9. A Two-County Profile of Reported Infectious Syphilis -1991 Hillsborough Pinellas White-Male 13% 11% White-Female 6 % 5% Black-Male 46% 47% Black-Female 34% 36% Other 1 % 1 % (Florida, The State of 1991:55,65) I notice that for each county, African Americans reported a disproportionately high percentage of residents suffering infectious Syphilis. Incidence of Gonorrhea have also been declining in the two country area. Hillsborough Country reports that in 1986, there were over 6,200 reported cases. By 1989, the case report was a little over 4,200. By 1991, there were under 2,900 reported Gonorrhea cases.

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95 Pinellas County reported similar results. In 1986, there were over 4,100 reported cases. By 1989, the number had dropped to under 3 000. By 1991, there were under 2, 200 reported Gonorrhea cases. Table 10. A Two-County Profile of Reported Gonorrhea-1991 Hillsborough Pinellas White-Male 9% 9% White-Female 10% 10% Black-Male 44% 41% Black-Female 35% 28% Other 1 % 11% (Florida, The State of 1991:56,66) I notice that for each county, African Americans reported a disproportionately high percentage of residents suffering Gonorrhea. We learn of other disease incidence from Florida Morbidity Statistics 1990. The following data concern known vaccine preventable childhood illnesses. Statewide in Florida, 1990, there was a total of 216 reported cases of Hemophilus influenza meningitis. This represents a nineteen percent decrease from just a year earlier and it is the lowest annual total on record. Nonetheless, ninety percent of the cases were in children under age five. Incidence among non-white males and females

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96 was five and three times greater respectively than among white males and females. Incidence among males was somewhat higher than among females, which was due to the high incidence among non-white males; the white population showed no sex differences. In the same year, over six hundred cases of measles (rubeola) were reported in the state, an eighty seven percent increase from just a year earlier. This represents the largest number of Florida measles cases in a decade. Further, the 1990 incidence of measles statewide was over 4 5 percent per 100,000 population, a seventy seven percent increase from the 1989 rate. The preschool age group, children under five years of age, had the highest disease incidence. Sixty percent of these children were too young for routine measles immunization. The fifteen to nineteen year old school aged population also had proportionately high measles occurrence. Table 11. Measles (Rubeola) Incidence Per 100,000 Population By Race and Sex, Florida, 1990 White-Male ............................ 3. 9 White-Female .......................... 3. 7 Non-White-Male ........................ 8.3 Non-White-Female ...................... 8 1 (Florida, The State of 1990:80,81)

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97 I notice a significant difference in the statewide incidence of measles (rubeola), between the white and non-white populations. I believe it helpful to compare the Florida data to information gleaned from another high population state. The Ohio Commission on Minority Health was created in 1987 in response to a perceived disparity in health status between minority and non-minority Ohioans. Its mission is to try to ameliorate the. diseases and conditions which cause excess deaths among the state's economically-disadvantaged African Americans, Hispanics, Native American Indians and AsianAmericans. Among the commission' s findings reported in Moving From Vision Toward Victory ( 1991) a clear pattern of minority population health care disparity emerged. It seems that the state' s minorities are dying prematurely due to: cardiovascular disease (primarily hypertension) diabetes, cancer, infant mortality, substance abuse, and violence (primarily homicide). I observe that many of these maladies are preventable and the deleterious effects of others might be reduced if noticed at early stages. The lack of comparable health status of Ohio's minority population can be exemplified by two statistical methods: Excess Deaths and Years of Potential Life Lost (YPLL). Excess deaths are defined as the difference between the number of deaths observed in minority populations and the number of

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98 deaths which would have been expected if a minority population had the same age specific death rate as the non-minority population. This method quantifies the number of deaths that would not have occurred if minority mortality rates equalled those for non minorities. The Governor's Task Force on Black and Minority Health (1987), has presented some important, if sad data. They are here presented. These data indicate a significant disparity between the general healthiness of African Americans and the majority white population. The report notes that common risk factors shared by these diseases are: smoking, excess consumption of alcohol, poor nutrition, sedentary lifestyle, and substance abuse. These identified risks, however, are not exclusively responsible for this disparity. The findings suggest that broader issues such as access to the medical system, the cultural sensitivity of health care providers, and perhaps most importantly, the ability to pay for health services must be addressed. Not surprisingly, Ohio's minority population is disproportionately poor. In 1980, the percent of families at or below the poverty level for Whites was 6.3 percent compared with 24. 1 percent for blacks, 19.3 percent for Native Americans, 18.1 percent for Hispanics and twelve percent for Asian and Pacific Islanders.

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99 Table 12. Years of Potential Life Lost by Cause of Death and Race Group, Per 100,000 Population, Ohio, 1984 White Black Asian-Americans Native-Americans Heart Disease 650 1,250 375 100 Stroke 75 225 125 Lung Cancer 175 300 75 25 Other Cancer 500 875 450 425 Homicide 100 875 175 300 Suicide 275 300 200 225 Diabetes 50 150 25 125 (Ohio, The State of 1987:12) The Task Force found that poverty imposes a pattern of living which directs all income to the basic needs of food, clothing, and shelter. Meeting these basic needs on limited incomes does increase health risks of minorities in general and African Americans in particular. Recall too, that poverty often results in inadequate and overcrowded housing, poor nutritional status, stress, and access to health care services only at times of acute illness. The report finds that the most significant variable which explains the difference between white and black conditions of health seems to be socioeconomic status. Apparently, socioeconomic status affects: access to health services, nutritional condition, immune state, educational level,

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100 employment chances, programmatic awareness, attitudes, and well body practices. The study revealed that lower income African Americans compared to higher income African Americans, are less likely to have regular Pap tests, are less than half as likely to have heard of proctoscopic examinations for colorectal cancer, and only one third as likely to have heard of mammographic examinations for breast cancer. The idea of a community health care intervention for the purpose of changing people's perceptions and knowledge of how they might help themselves, offers a hopeful way out of some of the disparity. In 1986, the Special Populations Division of the National Cancer Institute (NCI) designed a communitybased health education and screening effort for the purpose of reducing mortality from breast and cervical cancer among African American women who live in 10 poor areas of Chicago's south side (Lacey, Phillips, Ansell, Whitman, Ebie, Chen: 1989). NCI designed the project with the cooperation of the University of Illinois at Chicago's School of Public Health, Cook County Hospital, and the Chicago Department of Health. The intervention consists of delivering. education and information within the community. An immediate outcome of this effort was to be program related cervical cancer screening in two local clinics. The project's guiding hypothesis is that the health beliefs of a group contribute significantly to its member's

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101 participation in preventive health services. With this idea in mind, outreach staff members distributed specially designed flyers and posters to designated community contact points. Staff members explain the purpose of the program to people managing the contact points in order to gain their continuing cooperation. A variety of contact points were selected. Businesses were frequently chosen. The choices included: beauty shops, grocery stores, laundromats, clothing stores and pharmacies. These businesses were selected because women in the community frequently used them. Other selected sites included: local public libraries, religious institutions, public housing facilities and schools. The outreach in the schools, for example, was to include information packets to be sent home t o children's parents semiannually. Also, outreach presentations were to become a regular feature at PTA meetings. The program was designed in the hopes of creating a model for the delivery of community-based cancer control intervention. The program planners believed that if the intervention were to succeed, it would serve the dual purpose of bringing women into the program as well as strengthening community organizations and their links with residents. The effort holds promise. The next series of references seem to have a common theme of the study of ethnic groups and their perceptions of their

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illnesses. It understandings seems of 102 that these sickness and groups have at times, idiosyncratic ways of seeking a remedy. particular seemingly The idea of taking community atti tude. s into consideration to improve neighborhood health is not particularly new to the social sciences. Sociologist Robert N. Wilson (1970) said that "health care is a community affair." As such, he thinks that an overriding problem of public health is the mobilization of a community for a concerted attack on what he called "health deficits." He believes that an appropriate organization of health services requires a close knowledge of local health problems. He thinks too, that a health providing institution should have an understanding of community attitudes towards health, health helpers, and their own health conditions. At the time of his publication, it seems that what the author refers to as a "trite phrase" is something with which he comfortably identifies. He agrees with many of his contemporary public health officials who say that "the community is the patient." In this regard, it is believed that health professionals should orient themselves to the health of populations considered within their social settings. The author continues that a sophisticated social survey is a prerequisite to community medicine. He equates the importance of this survey to the taking of a medical history of a particular patient. He says that in community medicine, events must be placed in context. Wilson believes that only

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103 when health professionals possess a reasonable community baseline can an attempt be made to measure the consequences of public health action. Minimally, in his opinion, those who would presume to treat, require five orders of information. First, they would need to know what the dominant values and beliefs that govern the group's outlook on the world are. Second, they should consider what concepts of health and sickness are most firmly held. Third, he asks how people are arrayed in family structures? Fourth, he believes that providers must be aware of the local dominant political and economic institutions. Finally, he would wish to learn with which groups of both formal and informal organization do people identify. To sum up his position, he borrows a famous quote from George Bernard Shaw. Because it is germane as well as amusing, I too borrow the play on the golden rule first written in Man and Superman. It was here that we find, "Do not do unto others as you would that they should do unto you; their tastes may not be the same." I think a good working definition of "ethnic group" is provided by Hazel H. Weidman in her extensive study, Miami Health Ecology Report Vol. 1 & 2 (1978). She says, the term is generally understood by anthropologists as referring to a population which ... 1. is largely biologically self perpetuating

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104 2. shares fundamental cultural values, realized in overt unity in cultural forms 3 makes up a field of communication and interaction 4. has a membership which identifies itself, and is identified by others, as consisting a category distinguishable from other categories of the same order In one ot her works many surveys, her research team sought to rank the most serious health problems as identified by several Miami area ethnic groups. I think it interesting that different ethnic groups have particular ideas of how often they succumb to certain maladies. Indeed, they may in fact, get sick "differently." Table 13. A Ranking of Serious Health Problems As Perceived By Several Miami Ethnic Groups Southern Black Puerto Rican Cuban Haitian 1. High blood pr. Asthma Nervousness Pain/ body part 2. Heart Condition Nervousness High blood pr. Reproductive problems 3. Nervousness Headaches Operations Headaches 4. Asthma Arthritis Anemia Skin problems 5. Headaches Cold/flu Diabetes Appetite Loss (Weidman 1978:309)

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105 The Weidman team examined ethnic groups and their traditional healers. They queried African American root doctors and their patients as well as Puerto Rican Spiritists and their clientele. The methods of the helpers are extremely different. They tie into very different health care cosmologies. But what they do have in common is their effort to improve the patients' sense of well being. Weidman says that both health care world views include "matters of health and sickness as well as matters related to maintenance of self esteem" (1978:593). Cuban patients' membership in "clinicas" is studied. It seems that in a tradition begun in Cuba, neighborhood residents could pay a monthly fee and join a local "club" for the purpose of everything from job leads to Saturday night dancing. Included in the membership dues was an availability to use the clubs' health care facility. The local Miami patient population was studied to learn which particular ethnic groups made use of various types of health care clinics. The study found that twenty one percent (200,000 people) of the surveyed Cuban population periodically visited the clinicas. Only four percent go to the hospital emergency room as first resort. Among the questioned Puerto Rican population (without a similar clinic tradition), eighteen percent first sought out the hospital ER.

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106 I learned some very interesting information in regards to Puerto Rican female patients and physician visits. The study found that usually, Puerto Rican women were shy and embarrassed about seeking out medical attention. The author found that due to the "machismo" element of Puerto Rican culture, going to see the doctor was viewed by many husbands as almost cavorting with another man. Weidman also found that among Spanish speaking families of all ages, the health of boys was cared for more than that of girls. Boys were given more frequent health check-ups. When ill, boys were brought to medical attention earlier. She says black families, which are traditionally maternally oriented, tend to have girls seek health care more regularly. The author speculates that blacks feel that boys can better take care of themselves and therefore families seek relatively less care for their sons. This same Miami Health Ecology Project contacted patients of all area ethnic backgrounds and asked them to record a diary of symptoms and how they were treated. The researchers found that African American patients were the least descriptive group in terms of writing down their health symptoms or conditions. Here is an example of the technique ... Family [A]: January 1st through January 7th, the mother wrote "nothing." On the 8th and 9th, she noted that her husband had suffered "aches and pain" due to a cold and had taken cold capsules and Bufferin. She had entered "nothing" for the following day. It was not the Project field-worker was mak1ng out T1me Loss Chart" and asked if the father had m1ssed any work

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107 that she discovered that the father no longer worked because of a brain tumor operation 2 years The mother, not surprisingly, was reporting dur1ng the week, "headaches, feeling tired, nervous, pa1n near heart, worry about things a lot." During the third week of reporting ... an entry was made, "husband woke up acting strange, like a mental person." His wife took him to Jackson Memorial Hospital where he was hospitalized. (Weidman 1978:537-538) Weidman also compiled a glossary of ethnic symptoms and conditions. A few examples are presented here. Southern Blacks Falling-Out. A condition characterized by a sudden collapse, during which the eyes usually remain open but "not seeing" and with hearing unimpaired. Before collapse, patients often report weakness, "swinging" or "swimming, in the head. The semi-conscious state is usually .brief but of varying duration. It is said that "high blood" is the primary cause of falling-out; although at times, "low blood" had been implicated. High Blood. A condition in which the blood collects high in the body and tends to stay there. It can cause "swimming" or "swinging" in the head. Also, it is a state in which the blood rushes to the head. Unclean Blood. A condition in which impurities have collected in the blood after a period of time. Typically, this is complained of during the Winter months (though the report compiled in Miami), when the blood is "thickened" and carries more "heat."

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108 Run Down Condition. A state characterized by weakness and listlessness, affecting children as well as adults; it is said to be improved by "building up the blood. Misery-A state of dull pain, which can be either local or generalized. It is said to be related to physical, rather than environmental or social problems. It's a term not commonly used by young people. Puerto Rican Pasmo-A condition of sudden onset, characterized. by stiffness or paralysis of a body part, usually in the face, neck or head area. It may occasionally refer to general paralysis. The cause is said to be the incompatibility of an overheated body coming in contact with cold air from either a natural breeze, an air conditioner, or a refrigerator. La Monga. Influenza (flu) andjor the extended period of discomfort viewed as the aftermath of the flu. Ventoledad. Sharp, stabbing pains of sudden onset which may occur in any torso location. The pains may shift their location instantly and may subside as quickly as they began. It is believed that "the gasses are running loose," as they cause instant pain wherever they "strike" the body. Cintura Abierta. "Open waist," is a condition characterized by sharp pain in the middle of the back and around the waist. Opresion. The primary symptoms of this condition are a heaviness or pressure in the chest area, accompanied by

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109 shortness of breadth. Sometimes sadness with crying spells are part of the symptomatic venue. Cuban Empacho. A condition in which excess. amounts of food in the stomach are not digested. It is said that excess food "forms a ball and becomes attached to the wall of the stomach." Common symptoms include abdominal hardness, stomach ache and vomiting. Nervismo. A condition marked by fear, anxiety, tension, and general nervousness but defined in various specific ways by different individuals. Opresion. Same as above but it is said to be linked in Cuban culture with intolerable personal situations. Susto. This condition is a sudden fright which ranges in variation from a slight startle reaction to great fright. Typical symptoms include palpitations, weakness, sweating, and tremulousness for brief periods of time. Mal de Ojo. Illness or misfortune caused by an individual with the ability to project harm through the power of their eyes. A glance or direct gaze by such a person is said to cause childhood symptoms such as crying, vomiting, diarrhea, and fever. Death can occur. From the example of this glossary, Weidman's use of the term "health culture" is elucidated. Before explaining this term, however, it is best to present her and a colleague's definition of culture. As such, "culture is a group's design

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110 for living, a shared set of socially transmitted assumptions about the nature of the physical and social world, the goals of life, and the appropriate means of achieving them" (Weidman and Egeland 1973:848). The term health culture is borrowed from a 1967 study conducted by a scholar named A. S. Montalvo as he worked in a rural Peruvian community. In the present context, the authors say that "health culture refers to all of the phenomena associated with the maintenance of well-being and to problems of illness with which people cope in their own traditional ways and within their own social networks" ( 850). Given this perspective, Weidman and Egeland call for a fully integrated behavioral science intervention into particular ethnic population's health culture. This approach requires simultaneous attention to anthropological (cultural, ethnic), sociological (class, structure-function), and biological (symptoms, disease) factors. The authors believe that a "behavioral science perspective, "preserves the dignity of individual and group differences" ( 857). In their view, the solutions to health care delivery in the United States should proceed with an integrative understanding of region and indeed, community. Considering our "health culture" definition, it would seem that to effect a sensitive and successful intervention, health professionals should really try to glean an understanding of their community's parochial family and

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111 friends networks. Evidence provided by anthropologists Pertti J. Pelto and Jean J. Schensul (1987) is instructive here. They report that in Hartford, the Hispanic Health Council of which Schensul was a Director, received a federal grant to form the Comadrona Program in an attempt to improve the health behaviors and health outcomes of Puerto Rican woman. The program's methodology combined the notions of cultural brokerage and social support networks. The results showed that the formation and use of familial and social support networks such as neighborhood groups, could improve early entry and continuous involvement in prenatal health care. The authors do acknowledge that such success is not likely to be exactly translatable across all ethnic identifications. Yet, they do say that health programs directed to particular ethnic groups will more likely achieve success if the working programs include considerable investment in research on neighborhood specific features and conditions. In a similar way, I am informed by William A. Vega et al. in an article entitled "Social Networks, Social Support, and Their Relationship to Depression among Immigrant Mexican Women" (1991). The researcher's study was an attempt to learn if low income women of Mexican descent who had been living in a San Diego neighborhood for at least two years, were more likely to be depressed than Mexican Americans who had been living in the U.S. longer.

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112 In order to find their answers, the researchers interviewed members of these immigrant support networks. Interestingly, what they discovered was that country of origin family members were offering increasing amounts of emotional support. The key variable for this group of women was not network size but the amount of quality time spent with family of origin members. Even friendships were viewed as less significant. The results demonstrated that this group of women were not more likely to be depressed than people of Mexican descent with a longer U.S. residential history. This account is presented to suggest the importance of the health care providers' need to understand their particular clientele. For example, in this case, a future CHC representative might know to make a particular network contact in an effort to provide health care to these low income Mexican and Mexican-American women. Colleen L. Johnson and Barbara M. Barer (1990) help us to understand that the ideal of care giving is well entrenched among African American extended families. The authors demonstrate that by employing white middle class criteria, the family structure of many lower class African Americans appears to be unstable. Yet, what many researchers apparently miss, is that African Americans extend care giving networks right to the edge of their kinship networks. Further, the authors demonstrate that when actual blood relationships d6 not exist among the interested parties, fictive kinship is created. Much

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113 of this fictive kinship network, particularly for African American women, emanates from local churches. Johnson and Barer, also explain that for the most part, the impact of social service helpers, particularly in the case of the elderly, has proved beneficial for their studied African American respondents. It seems that not only was their help appreciated, but many receivers of aid considered the frequently visiting assisters, to be fictive kin. These formal systemic interventions offered another important benefit. They relieved some of the stress on friends and families so that the time seniors spent with them was of higher quality. Network members need breaks too. More than whites, African Americans stretch active relationships right to the edge of their kinship blood line. They are also active in creating fictive kinship. The knowledge by health care center personnel of this very different family construction, can be a boon to the center, its patients and their families. As the impact of social service help is documented, professionals should certainly have as much information as possible concerning how their respective populations may be attracted to germane institutions. In this manner, Rao and Rao (1983), conducted a study of 240 senior African Americans in Jackson, Mississippi. They discovered that there were very different predictors of use of service among the tested male and female populations.

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114 The authors found that the three most used help programs by these seniors were: the Mini-Bus Program, the Nutrition Program, and the Home Delivered Meals Program. That said, the most powerful variable by far, related to service use by males was "life satisfaction." Perhaps the men had to feel good about themselves before they would seek service support. A distant second was labelled "help received from children." Interestingly, help received from children did not make the female list as a predictor. Among queried women, what was number one was "occupation." Apparently, if women on the job heard of an offered service, they were more likely to take advantage of it. The category of "occupation" did not even make the male list. In second place for women was frequent "talks with siblings." Third was frequent "talks with grandchildren." Perhaps outreach workers employed in African American communities with a large proportion of seniors, might wish to consider entry to potential female clients through job networks and sibling/family relationships. I note that "life satisfaction" while an overwhelming number one with men was a very distant fourth for these senior women. Fundamentally, the Rao and Rao data indicate that senior African American men and women require different venues and stimuli for them to reach out for social service assistance. The authors urge that public and private policy planners and implementers become cognizant of the different

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115 factors affecting knowledge and use of social services by males and females. The literature seems to provide mounting evidence of contemporary ethnic group health care vulnerabilities. Informative evidence is offered by the ASTHO Bilingual Health Initiative (1992) report. ASTHO stands for The Association of State and Territorial Health Officials. At the time of this report, the ASTHO Minority Health Advisory Committee was chaired by Joycelyn Elders, MD, Arkansas Department of Health. She later became Surgeon General of the United States. The report is illustrative as various state health officials have begun to recognize particular problems faced by minority populations. For example, the report recommends that training of agency staff and health providers should address the following issues: cultural values and traditions, family structure, communication styles, attitudes affecting health behavior, approaches to healing, and traditional folk remedies of the targeted populations. It is recommended that training should also address mental health issues and stress management. This same account provides informative statistics. For example, the diverse population of Hispanics in the United States includes people of Mexican, Puerto Rican, Cuban and Central and South American descent. Their presence represents 8.1 percent of the country's population. Yet in 1989, sixteen percent of people with AIDS were Census classified as

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116 Hispanic. In Texas, the rate of Hispanic morbidity from diabetes compared to that of the non Hispanic white population was more than two to one. But we also learn of health disparities between Hispanic subgroups. For example, Hispanics have a 5.6 percent risk of low birth weight babies overall: Non-Hispanic whites have a 5.2 percent risk level. Yet, the rate for Puerto Ricans is much higher than average at nearly eight per cent while the rate for Cubans is below non-Hispanic whites at five percent. The group formally classified as "Asian and Pacific Islander" represents three percent of the entire U.S. population and fifteen percent of its minority population. For these people, health indicators also fall below those of the general population, in addition to varying significantly within their own ethnic subgroups. Problems associated with low birth weight among Asian and Pacific Islanders reached a rate of 6.5 percent in 1980. For Filipinos, the rate was 7.4 percent compared to the non-Hispanic white rate of 5.6 percent. A number of major barriers separating minority populations from adequate health care have been identified. The most powerful variable seems to be language difficulty. Other variables include: cultural misunderstanding, ignorance of the local health care structure, and financial vulnerability.

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117 Presently 1 a majority of states have policies which provide educational and informational material in languages other than English. Some states have policies concerning the use of interpreters. Fewer states, however, have policies addressing the training and hiring of bilingual health care workers or the hiring of bilingual agency staff. Texas does. There, many community programs train lay workers from the communities to participate in screening and health promotion activities. Also1 community residents are generally hired to staff health care centers. For example, the Cetro Medico del Valle, Inc. is a grass roots community project with a mission to increase bilingual and bicultural access to primary care service on the U.S.-Mexico border. Health care directors in Colorado have developed the Refugee Health Care Access Program. Its purpose is to provide an effective communication bridge between refugee families and health care providers. Their bilingual staff, currently consists of six community health workers who speak English and Vietnamese 1 Khmer (Cambodian) Laotian, Hmong, or Russian. Staff training includes: education on the principles of preventive health care1 standards of routing well-child and maternity care1 techniques of contacting, interviewing, and informing refugee families 1 techniques for providing effective interpretation services, and procedures for keeping case records and completing activity reports. Given the inclination of many refugees to seek care from the American health care

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118 system for curative rather than preventive purposes, the bilingual health workers particularly, try to reach at least ninety percent of the targeted population for many remedial objectives. There are thirty-five states and one territory listed as members of ASTHO. Two-thirds of the members presently obtain input from linguistic minority communities for the purpose of developing health policies and programs. Methods of community contact include: meetings with community representatives, meetings with local government, public hearings, and surveys. Among the ASTHO report's recommendations, I present the most germane: -define the target populations to be served in terms of cultures and primary languages as well as risk factors -identify individuals and groups from local cultural and linguistic minority communities who can help plan and implement programs -plan and implement a client data base that would allow for evaluating the use of the services by cultural and linguistic minority populations -English materials should be adapted, not merely translated It does appear that state social service agencies are paying increasing attention to issues of cultural diversity (ASHTHO 1992). The maternal and child health programs of the federal government's Public Health Service have for decades been

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119 primarily directed towards low income and minority populations. However, the agency reports (Hutchins and Walch: 1989) that recent surges of immigrants from Asian and Central American countries have caused government policy analysts to appraise their efforts to meet the special needs of these people. Through grants for special projects of regional and national significance (SPRANS), the Office of Maternal and Child Health is funding projects to break down language and culture barriers to health services for pregnant women, infants and children. Additionally, the Office of Maternal and Child Health (OMCH) has established a Workgroup on Culturally Distinct Populations to survey the special needs of these newer arrived minority populations. The Workgroup is expected to advise the OMCH on how it could best employ its grant monies to improve the health care of these various minorities. The issue of ethnic sensi ti vi ty and the provision of health care has begun to be made policy manifest in a variety of ways. For example, the OMCH has provided a grant to two New Haven community health centers. These two centers developed a program to reduce adverse perinatal and infant outcomes among primarily Puerto Rican clients through outreach activities for the male partners. Further, health center staff are involving both partners in prenatal visits, postpartum classes, and activities for the male partner including job counseling and training.

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120 Program success has not come easily. Problems outreach employees have encountered include attitudinal barriers and the transient nature of the population. Though rather slowly, many of the participating men have overcome their original feelings about using the health center. Another example of OMCH granting largesse is its funding of The Southeast Asian Development Disabilities Prevention Program in San Diego. This program provides outreach, identification, intervention, and education services for at risk infants for developmental disabilities in local Southeast Asian communi ties. The project's goals are to expand the network of coordinated community services for this underserved population and to increase the education and awareness of local Southeast Asians regarding the need to prevent developmental disabilities. To this end, the staff has developed educational materials in several Asian languages. For example, a videotape entitled "Baby Care," has been produced in Cambodian, Hmong, Laotian, Vietnamese, and English. The importance of a culturally sensitive illness perspective is further illustrated in an article entitled "Alzheimer's Disease in Cultural Context" by Neil J Henderson (1990). The author shows that among Cuban people living in Tampa, the symptoms of Alzheimer's Disease are viewed by many as a person going "crazy. Further, this craziness is a source of family shame as for among other reasons, the symptoms are

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121 believed to be hereditary. It is also a tradition among Cuban people, to be stoic in the face of familial pain and suffering. The article demonstrates that within these cultural mores, a social service agency can offer effective and compassionate intervention. The intercession begins as care giving mothers and daughters of Alzheimer suffering fathers are contacted about an ongoing Alzheimer's support group. The daughter is a key family member in this regard as it is females, rather than males; who normally are responsible for issues of health. As importantly, this younger generation has more experience with formalized institutional interventions than their mothers. During the first support group meetings, the author notes that mothers are often quiet, likely embarrassed, and sad. Frequently, the daughter does the talking on their behalf. But often after a few meetings, the older adult begins to join the discussion, thereby reducing the importance of the adult daughter as the bridge to the meetings. As time goes by, as the mother feels more comfortable, the daughter's presence is no longer required. The mother frequently opens up to the other women and real bonding takes place. These new "family" affiliations, often help to make household relationships less stressful and therefore more stable. These next several references highlight the importance of studying and then responding to particular community health care priorities. Stephen L. Schensul and Maria Borrero (1982)

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122 offer instructive means to learn about a community health profile. In this regard, they discuss the creation of the Hispanic Health Council. The council is a research, training and advocacy organization. It's goal is the improvement of the health of Puerto Rican people living in Hartford. It was organized because it was perceived by community activists and anthropologists that people in the various neighborhoods lacked the formal skills to respond to community care problems. Additionally, it was recognized that there was a dearth of information about Puerto Rican health behavior, beliefs, and means of training bi-cultural health care staff. A formal collaboration between community activists and anthropologists developed. In their effort to obtain health information about local Puerto Rican neighborhoods, they obtained a three year grant from the National Institute of Mental Health. To help conduct research, University of Connecticut medical anthropology students were brought on board. They gave to the effort their anthropological experience, and they in turn received training in community health research, program planning, intervention models, and curriculum development. Selected for comparative research were two very different local Puerto Rican neighborhoods. One was a primarily private detached home community near center city. The other, near the outskirts of town, featured a public housing facility.

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123 The methodological steps in the project included the following: 1. Collection of life history data to establish Puerto Rican migration experiences 2 Ethnographic description of the two neighborhoods with an emphasis on social service resources 3. Interviews with residents on the ways they handled related health problems 4. Interviews with "providers of services" including representatives from hospitals, "clinics," police and fire departments, social service agencies, botanicas, as well as pharmacists, espiritistas, clergy and others. 5. A household health interview schedule was created, pretested and finalized. The testing device included over 200 questions relating to demographic background, health behavior, beliefs, and health facility's use. Over 150 residents were queried. I ssues identified through the analysis of the survey data became the central points of emphasis of the Hispanic Council. These issues included: sterilization, otitis media, asthma, crises intervention and family health. Switching from their research role to their identity as community health advocates, the Council established the following programs: free postpartum health education, minority recruitment into the health fields, a learning resource center in Hispanic health, a program to train international professionals in

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124 community health research, crises intervention, and family health support programs. The data suggest that neighborhood specific health care intervention may prove to be an effective way to help people. Community and Migrant Health Centers: A Key Component of the U.S. Health Care System (1991), reports that these centers provide care for nearly six million Americans. The centers have over 22 million annual patient encounters. The data also compare the ethnici ty of the U.S. population against the population attending urban community and migrant health centers. The results are as follows: Table 14. The Ethnic Categorizations of the U.S. Population and the Population Attending Community and Migrant Health Care Centers U.S. Population White/Non-Hispanic African American HispanicjLatino Asian/Pacific Islander Native American Other 73.7% 11.1 8.2 2.7 7 3.6 Urban C /CMC Patients 29.9% 37.0 27.2 3.2 .8 1.9 (National Association of Commun ity Health Centers 1991:15) Community and migrant health centers provide care for a number of special population groups which are targeted for care due to their unique needs. These groups include: the unemployed, substance abusers, migrant and or seasonal farm workers, pregnant women, the homeless, and persons who are

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125 HIV-infected or have AIDS. The unemployed represent nearly thirty percent of patient population. I note that nearly twenty two percent of urban center patients speak limited or no English. In order to meet this challenge, sixty five. percent of urban centers employ a translator, sixty two percent employ bilingual nurses, seventy two percent have hired bilingual physicians, and thirty two percent engage bilingual dentists. The majority of CHC physicians are primary care specialists. Outreach workers or community health workers are generally area residents who have been trained to identify high-risk potential patients. Outreach personnel help patients access the health system beyond the health center, follow up with referrals for additional medical and social service, and provide basic health education. The importance of having locally aware and ethnically sensitive health care providers is exquisitely portrayed by Arthur Kleinman in his book Patients and Healers in the Context of Culture (1980). Here he finds that people's belief's about sickness, the behaviors exhibited by sick persons, including their treatment expectations, and the way sick persons are responded to by family and healers, are all aspects of social reality. He says they are cultural constructions, shaped distinctly in different societies. They are also explicitly shaped within different social settings within those societies. These beliefs systems are

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126 part of what Kleinman terms "clinical reality." He defines clinical reality as "the beliefs, expectations, norms, behaviors, and communicative transactions associated with sickness, health care relationships, therapeutic seeking, activities practitioner-patient and evaluation of outcomes" (42). In this regard, he distinguishes the terms "disease" and "illness". He defines disease as the biological or physical malady that is impacting the body. Illness on the other hand, is the individual's, or valued communities' understanding and expectations related to the malady. This, he says, is culture specific. In discussing his research in Taiwan, Kleinman reports that families often accompany the patient to the health practitioner. As a family member, an individual is considered a part of an immortal family network which includes ancestors and progeny. In this context, it is understandable that families have great influence over health care decisions which at times supersedes the patient's own opinion. The differences with the western medical model are more pronounced still. For example, Taiwan families were interviewed concerning sickness episodes. It seems that among the 115 families queried, sickness episodes first receiving family care (before visiting a formal practitioner) were ninety three percent. Total sickness episodes only receiving family care was as high as seventy three percent. Among children, those first receiving family care was eighty eight

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127 percent. Those only receiving family treatment were fifty eight percent. I found fascinating another difference in medical perception. In this regard, I recall my own less than calm demeanor when visiting the doctor. I want to know everything. I often come in with a list of questions and in practice, ask many more. By the time I'm quite through, I'm hoping the doctor's responses had been encyclopedic. In contrast, Kleinman says that in Chinese culture, the popular medical ideology holds that the skills of a practitioner are demonstrated by their ability to ascertain what is wrong from the pulse and perhaps from a few short questions. He notes, the fewer the questions, the better. He reports an old saying that "a great doctor asks nothing" (262). The practice environment is quite different as well. It seems that it is common in Taiwan for a patient-doctor meeting to take place "in a room with other patients and families present. The patient would place their hand on a cushion (often tattered) and the doctor feels the pulse. The doctor may ask a few questions and then prescribe medicine. The physician offers a fuller explanation only when asked. The author's perceptions highlight (at least for me) the importance of a practitioner's understanding of an ethnic group's clinical reality. But his observations also suggest practical outreach strategies for contemporary urban health

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128 care practitioners. He says that health care systems may be both socially and culturally unified on the local level or in the same locality, multiple and not integrated. For example, a particular neighborhood in say, New York City, may contain large numbers of Koreans, people of Puerto Rican descent as well as Jewish Hasidim. The data suggest that optimal health care can be offered by practitioners who are ethnically sensitive and neighborhood wise.

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129 CHAPTER 3 CULTURE OF THE COMMUNITY Having stated that the theoretical orientation of this practitioner is one labeled in anthropology "cultural ecology" it may be helpful to the reader if I provide a brief description of the community where the subject health center functions. In this chapter the center should come to be seen as part of a local ecosystem. Although a detailed narrative of the organization's birth will be presented in the next chapter, in this one, I hope to provide the reader with a sense of how the center could have come to life from "this soil." Beyond that, the reader may ultimately judge whether this institution i s particularly effective as a place people would want to use to satisfy their health needs. Welcome To The Neighborhood What one would notice upon first walking along the avenue where the health center resides, aside from the view of elegant trees as far as the eye can see, is the variety of housing stock. Certainly at the lowest end of this continuum are the abandoned boarded up structures. After an informative

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130 walk about or a neighborhood drive through, one would surmise these represent approximately 10 percent of the visible structures. On this same perusal, you could not help but notice that you are in a very lively community. There are many walkers; Kids are flying by on bicycles. There is a great deal of automobile traffic. People talking from car to car is not an infrequent occurrence. School buses are a familiar sight. Also, adults seem to know the corners to meet to find timely companionship. Roughly one third of the homes (there are few apartment buildings) could be called unkempt. Among this category, one notices broken screens or windows, mattresses strewn in the front yard, refuse in the front yard, absolutely no grass or flowers or in general, edifices in desperate need of repair. The majority of homes are neat and clean. Some are of brick construction which is certainly optional given the moderate Winter temperatures this middle sized southeastern city enjoys. Most have pleasant front yards and some resid.ents display great skill in horne gardening technique. The observer must notice some of the colors of the houses. These colors seem to emit vibrant household energy. Electric or neon blue is popular here. I notice a few homes adorned with neon yellow and I notice one home in particular with neon yellow brick. Lime green is another favorite as is bright pink. Two purple houses are short blocks from the

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131 Evelyn Perry Community Health Care Center (pseudonym) (EP) where I trained. A study of community ecology must include a description of the center where I conducted my internship. I surmised this from the anthropologically familiar "outside" perspective which helped me to consider that potential clients would be more comfortable in a setting which looked like much of the rest of the neighborhood. The equally familiar "inside" perspective came forcefully to me as I learned that some potential clients might simply be afraid to see a doctor. The health center and the adjoining church are certainly neat and clean. The process of description and likely client comfort levels will be examined. Then there are the mansions. I don't mean large houses. I mean full fledged 40 room palaces. Some of these are presently being rehabilitated and transformed into contemporary homes. Professionals, both African American and white seem to be enthusiastic buyers. These edifices may represent only about 5 percent of the housing stock but they really stand out amidst this eclectic neighborhood. This city has a history dating back to the 1920's of being a mecca for wintering northern tourists. It was portrayed as a "paradise" of good health and good cheer. Today, it would be unlikely that the city movers and shakers would be taking potential visitors or future residents on a tour of this neighborhood.

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laws The housing stock is of the mid-1960's, 132 old and before the desegregation the neighborhood was almost exclusively "white African Americans only." lived in Before these laws took effect, designated neighborhoods. This circumstance existed because back in 1931, ''the city charter indicated that one of the city's primary goals was to set apart separate residential and business districts for negroes and whites" (Phillips 1994:318). In the 195.0's, the city council appointed a committee of African Americans and whites to determine new boundary lines for the burgeoning African American community. Ultimately, little change was recommended. That seems unfortunate because by the mid-1950's, African Americans represented 14.5% of the city population but were permitted r esidence on only 2 % of the land (Phillips:1994). The health center is located just seven blocks south of where one of the African American communi ties effectively ended. Therefore, it is certain that this housing stock is now occupied post-white flight. I would guesstimate that today, the community is approximately 80 percent African American and 20 percent white. This previously segregated housing pattern was made personal to me by two informative interviews. In one particular session in the office of an African American physician, he told me that in the 1950's, his office location very gently crossed over the known neighborhood line.

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133 Therefore, the only way he could occupy his office space was to have a white friend seemingly buy the building. The men had to make it appear that the physician was a renter. In fact, it was the doctor who put up the money for title but his name could not be on it. It was not until 1978 that he moved his office further south and indeed claimed ownership of his small building. In an interview, the health center's head nurse remarked that she found it amazing that she was living and working in the present location. This life long city resident of 60 years told me that when she was a girl, African Americans found in this part of town would be beaten up or worse. Now she lives in a very comfortable home near the health center. You can't miss it. It's lime green. The Community Health Care Condition The reader will, throughout the course of this text, become familiar with this community's health vulnerabilities. Writers must never get ahead of themselves. Still, at this time I will say that the director of the county health department speaking at an EP Board of Director's meeting warned of worrisome increases of Tuberculosis, Influenza, and Hepatitis. I recall as well that the Medical Director of the health center was also finding an alarming upturn in childhood Tuberculosis cases. She said that the children playing in the

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134 street were frequently exposed to filth and thus, the return of this disease. A very important question comes to mind. Does EP adequately address the health care needs of its constituents? We shall see in the text specific disease indications as well as patient groupings by medical practice category (Table 18). It is the author's intention that the reader be provided enough information to make a proper assessment. For example, the type of query I would suggest is if a community seems to have a high percentage of low income mothers, does the health care center respond to their particular needs? Within five miles of this community, there are two large hospitals, each with fine reputations. One is a children's hospital. The other is a predominantly adult general hospital. This facility has a clinic across the street from the ma.in complex. The relationship between these formal institutions and EP will be carefully explained in later chapters. As reported, the county has an active department of health. The community is also fortunate to have a "free clinic." And there are currently up to a dozen private practice African American physicians tending to the needs of neighborhood patients. Each of the these provider types will be later discussed vis-a-vis the health center. For now I will merely mention that a real issue in this community's health care dynamic is access. For example, I have had many health center clients tell me that they came to the

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135 institution because their previous provider was not open at night. The health center does operate at community convenient hours. That's important as both the director of the county health department and the EP Executive Director have publicly stated that even given all of the aforementioned provider services, including those of.the health center, only about one third of the community residents are being medically served. Community Politics-A History of Struggle Politics represents an important part of the culture of a community. That is certainly true in this community. You see it took the advent of the 1960's housing desegregation laws, to allow more physical space for this city's African American population. This population and its white counterpart are, however, still easy to find. As this study will detail, the overwhelming majority of the African American residents live south of the city's main street. Similarly, the overwhelming majority of white residents live north. Near the center of town there is some small section of racially integrated housing. The reader will later learn of smoldering not so latent racial tension. This local tension has precedent. The city did not accommodate integration easily. For example, on August 21, 1955 a main downtown city swimming pool was open to whites only. On that day seven African Americans attempted to

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136 purchase tickets to use the facility. The ticket seller immediately summoned police who told the seven to use the "negro" beach instead. At the time, African Americans were permitted one small beach area which was generally strewn with abandoned tires and soda pop bottles. On November 30, 1955, six of the would be swimmers filed suit against the city claiming that their constitutional rights had been violated. Numerous layers of federal courts agreed with the plaintiffs. Still, the city was resolute. It was trying to make the case that it had a "duty to operate the pool as a business enterprise and for the best interests of the inhabitants who are stockholders, so to speak, in this enterprise. If negroes were admitted, white patronage would practically cease" (Paulson 1982:10). The city lost in Federal District Court, in Circuit Court, and in the Court of Appeals. On April Fools's Day 1957, The Supreme Court refused to hear the city's plea. One year after the Supreme Court decision, eight African Americans sought admission to the pool. They swam for an hour without incident. The next day, however, the city closed the pool. This was to be the first of similarly reasoned four pool closings. Given the city's "wisdom," whites too, were barred from the pool. Amidst mounting political pressure, the city manager resigned in November 1958. It would be three and a half years after the beginning of litigation that the "walls carne

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137 tumbling down." Finally, on January 6, 1959, the pool was open for good as the city council passed the new ordinance by a one vote majority. There were several important reasons why the public facility fight was won. First, of course, was the litigation begun by the six African American plaintiffs. They were supported in their efforts by the local NAACP and an ad hoc association of Baptist ministries. Credit too, must be given to other African American would-be swimmers who later also attempted to integrate the pool. Second, and importantly, the white business community favored integrating public facilities. Well perhaps that's a little too generous. The downtown business community had a resort city to run. The last kind of publicity they needed to hit the northern newspapers was of racial strife. Thirdly, the local newspaper had by the mid-1950's, changed its stance from "separate but equal" swimming facilities to full integration. The paper proved to be a continuous thorn in the side of the city administration. At this writing, local power is officially politiqally represented by district elected city council positions. These seats were not garnered without struggle. In fact, it took a 1968 city sanitation strike to bring a new militancy to local African American leadership as well to the eventual changing of the guard in city government. In 1969, continued protest by African Americans led to the creation of the first predominantly African American voting district. In that year,

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138 the first African American was elected to city council (Phillips:l994). Presently, there are two African Americans on the city council. There are also six whites. Whether or not these distinctions impact city policy is just something the reader will have to determine. Separate and Unequal Since the 1880's "negroes" had a seemingly dual identi-ty in this city. They were originally enticed to town by the need for rail line construction. The railroad was built right to the center of town. In the new century, "Negroes" continued to "work cheap." They were called on primarily to do manual labor. But then, after work, the city leaders hoped that they would disappear. They did indeed disappear into their compact segregated neighborhoods (Phillips:1994). Apparently "negroes" weren't to be seen enjoying the pleasures of what was marketed up north as "paradise found." This same racist attitude had long pervaded local health care delivery. For example, in 1960 the city council proposed that a negro only wing be built at the city's "white" hospital. The suggestion was made because it was generally acknowledged even by local segregationists that the "negro" hospital was antiquated and dangerously overcrowded. There

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139 developed so much white civic opposition to the proposed "negro" wing that it was never built (Flemming:1973). Due to the implementation of federal civil rights laws and a more progressive city administration, the white only hospital was eventually integrated. The antiquated "negro" hospital served its last patient in 1967. Today, the integrated hospital in question has given way to the newer previously mentioned facilities. Pastor Power In the studied community, there is no shortage of "pastor power." There are churches everywhere. There are a number of large, formal and very beautiful western traditional looking churches. In fact, EP is itself physically attached to one such institution. But that is a small part of the theological architectural story. There are many church signs on private homes. The nearby avenues feature hundreds of storefront one room churches. All of these are open on Sundays. During the week, the ministers generally attend their full time jobs. In the weekly community African American newspaper you will likely find up to 80 announcements of local ministries. The overwhelming majority of these are Baptists. A few are Methodists. Two or three are catholics. The rest are "others." Usually, one or two announcements will feature female ministers.

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140 These pastors and their selected parishioners have power and do influence public opinion. This text will make the connection between some of these ministers and the community health center. The reader will be acquainted with this relationship as the birth of the health center is described. You will also go to a very formal African American church along with this writer, the EP Executive Director, and the center's Head Nurse. It is to this woman's church that the Executive Director was planning to ask for a donation. Finally, you will be able to consider how a closer relationship between the health center and local ministries might not only offer symbiotic assistance, but could bring important benefit to a considerable number of community residents. It is appropriate to note at this juncture that this observer did not find much unity among these religious oriented organizations. In both formal ministerial interviews and informal parishioner assessments, one heard more of the competition. Yet, I am pleased to report that on at least one overriding municipal issue, these ministers did very much pull together to register political opinion. Temporary umbrella organizations came to life. I must also say, however, that after the circumstance to be reported upon passed, the organizational unity could not be sustained.

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141 Other Helping Organizations I have described the formal health care institutions. But there were a number of other organizations which provide great benefit to the community. For example, located in the same facility as the health center is a separate organization which gives out clothing to young children. You will shortly read of the voluminous extent of their contribution. Located a few blocks from the health center is a very effective drug rehabilitation organization. Sadly, drugs are a community wide hazard. It will be demonstrated how a relationship between this organization and EP was forged for dynamic community benefit. Throughout the city and in this case, our studied community was not an exception, a very effective senior service organization provides help to elderly people. Among their prominent programs is a daily hot meal in both congregate facilities and for home shut-ins (Vesperi:1985). For shut-ins, there are numerous helping programs which are designed to keep recipients at home in an acceptable quality of life circumstance. Helpful programs for homebound elderly include: Occupational Therapy, Physical Therapy, Speech Therapy, Home Nursing Emergency Response, and Chore (housekeeping) Services. I am pleased to report that this fine

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142 group acted as a transportation aid to some of the center's elderly clients. An active community center is located a mile from EP. Among its program features are child day care and senior congregate hot lunch dining. The meal was served courtesy of the aforementioned senior service group. Regular lectures and classes of note include: Adult Basic Education, Building Self Esteem, Mental Health Services for Senior Citizens, Social Security and Medicare Assistance, and Children's Story Hour. A very good local library is a wonderful attribute of the community center. The collection is geared from pre-school through early college and it is really rather extensive. African American authors are always featured. Attendance seemed to this observer to be very high. During my study, I came American business oriented upon a chamber burgeoning African of commerce. Its geographical emphasis was south of the city's major thoroughfare. The reasons for this separate organization's birth shall later be made clear. Though it hadn't at the time of this writing, it would be wise for this new business organization to recruit some of the neighborhood's African American owned small grocery stores. That is, some actually were locally owned. At many of these, residents could purchase vegetables, fruits and other essential foods at prices consistently higher than those

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143 available at large supermarket chains. The obvious reason was that they were paying top dollar to their wholesalers. The two nearest chain supermarkets were each located three miles north and south of the health center respectively. Culture of the Community The Evelyn Perry Community Health Care Center is part of its community's ecological system. To elucidate the reader's perspective, other germane social service organizations have been presented. The relationship of EP with many of these will be more fully explained later in the text. Local politics is certainly part of any micro ecological investigation. A brief discussion of same has been presented here. Again, not to get ahead of ourselves, but the reader will come to understand the effect local politics and the undergirding African American-white community history has had not only on the health center's birth, but also on its present-day functioning. It is my hope that in this chapter, the reader has at least gotten a "feel" of the neighborhood. I have discussed the shape of and aesthetic look of local housing. I hope I have helped the reader envision the elegant trees and plantings which grace this community. Speaking of trees, I alert the reader to a different use of the term "tree" as a

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144 metaphor for an informal community meeting place, which will have an important bearing on the health center. This kind of neighborhood "feel" is helpful in placing the work of EP in some perspective. It the reader to better know EP's potential client base. Here now is a bit more feel. You are the only white person in Atlands Cafeteria (pseudonym) on Sunday noon. There are a dozen African American customers. As you move your tray down the line, you notice that the server is being extra nice. He is very proud of each and every home cooked dish. He responds when asked that the fried chicken is the best. You are also steered to the candied yams and black eyed peas. A smiling young woman tells me to be sure to tell her (pointing to a full pitcher) when I've finished my fresh squeezed lemonade. At your table, you notice that everyone is sneaking a surprised and approving glance your way. These customers are dressed. They are "Sunday go to meetin' dressed.11 Women are wearing elegant clothing usually topped with a more hat. The men are in handsome suits. The male server twice approaches my table and asks if everything is alright. He asks if I've eaten here before. I tell him where I work and that I often am a weekday customer. He then does a successful commercial for the hot home made peach cobbler dessert which turns out to be unbelievably good. He returns again, not with the check but with a flier.

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145 The neon yellow sheet announces the new Thursday lunch special. For $3.99 you can have lunch and from 11:30-2:00PM be treated to a saxophone and guitar inspired live jazz program. The server said that it would be an "honor to have you come." I hope you can feel the specialness. While at the center, I would try and get out to a community restaurant about once a week. This was also true for most staff. Still, most staff lives locally and the general pattern is to go home for lunch. A reason for all was economics. A reason for some was the care and feeding of their children. I have begun to present some of the health challenges with which EP and other provider institutions must come to grips. The other local health care institutions have been delineated. Their relationship with this community health center is a dynamic which will be further explored. It is my intention that the reader will ultimately be offered enough information to render a knowledgeable judgement as to whether the health center is itself providing quality community service.

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146 CHAPTER 4 METHODS I chose a qualitative research approach because I felt this was the best way for me to learn and then to communicate, the value that the community health care center at which I interned, has to its community. Shortly, the reader will be told of the specific means by which I studied the health center. All of these means of fieldwork lead to ethnography. It is the customary job of the anthropologist when going on site, to observe, analyze as best we can, record data, events and feelings, and then formulate ideas regarding a field experience. This is ethnography. The ethnographic methodological approach, is most appropriate for our task. The creation of ethnography suitably fixes the anthropologist into a posture of humility. This is so because as James L. Peacock instructs, ''the ethnographer is placed in the position of the learner, the student of what is to be taught by the culture" (1986:63). The scholastic stance of student observer rather than instant analyst or problem solver, permits in my opinion, a higher level of informative discourse. One of the reasons I had gone on site was to try from this specific experience, to add to a body of general

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147 knowledge. In this case, I attempt to assess the potency of care of a specific institution vis-a-vis a particular community. Yet, the research question I posed at the outset suggests a more far reaching response. As it does, I am heartened by Peacock's imploration that "ethnography must say more than it tells; it must imply and teach general significances through presentation of particular experiences and patterns" (1986:90). For now, I believe it is safe to say that an inductive scholarly reporting upon a specific case, has the potential to offer systemic implication. At the heart of anthropological research is fieldwork. Fieldwork as participant observation formally combines the anthropologist's on site experiences with their employed methods. Participant observation as the name implies, requires that the practitioner become an active community member. Yet one does not ''do" participant observation in the sense that you might construct something specific like a formal survey. The formal survey may be part of the participant's duties. But "participant observation is more a state of mind, a framework for living in the field" (Crane and Angrosino 1984:64). The accomplished participant observer acquires a depth of understanding and an appreciation of local nuance not possible in a study from afar. Because of participant observation, the anthropologist is far more able to interpret and describe the community under study. Therefore, the

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148 information communicated to the reader, can become a body of knowledge worthy of seminal policy purpose. I wish at this juncture to mention again, that my own theoretical orientation is that of a cultural ecologist. Given the de facto intellectual demands of this anthropological world view, I believe it necessary for me to tell the story of one individual community health care center. This account is particular, in a way that Julian Steward may have appreciated. I do hope that this work also adds to a more general body of knowledge that he might have, and that we do, find valuable. Obtaining The Internship The process of the internship itself observation. It is appropriate therefore to is participant "begin at the beginning," and describe how I carne to work at the Evelyn Perry Community" Health Care Center (pseudonym). The account may be instructive to others seeking similar engagement. I had the opportunity to interview with the professional organization representing all such centers throughout the state. From the list of centers in the state's central region, I suggested some interesting sounding names to the organizational leadership. After reading numerous CHC descriptions, I found one which particularly piqued my

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149 interest. The next day, I interviewed with its Director 110 miles away. My goal in seeking an internship, was to improve people's access to health care. I spoke of this goal to the center's Director. I asked him about the center's senior citizen patient population. He said they often were people who were "left behind" in the neighborhood. He explained that this constituency could not afford to move out as the neighborhood aged. He also stressed that the institution did not primarily serve seniors. This was the only information which caused me to hesitate. For months, I had desired to participate in solving problems of health care inequity for minority senior citizens. Yet, in terms of the economy, 1991 was not the best year to be looking for either work or an internship with gerontological oriented organizations. I had participated in many interviews. A professor of gerontology called friends on my behalf. Ultimately, I was not to be assigned. I saw that the center was indeed a busy place. The Director and I got along well. He agreed to take me on. He said, "I will try to find some money." In this matter, I balanced my concern for the survival of what seemed to be a desperately needed community facility, and the survival of Ron Rabin. The Director and I sealed the deal.

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150 The Setting The CHC was opened by local religious and political leaders eight years prior to my internship. It was envisioned as a facility which would care for the medical needs of low income community residents. It is open at hours which are convenient for community service. Special attention is given to Medicaid and Medicare registration. The organization is charged with offering counselling and health education. Establishing An Identity The Executive Director had informed me before I actually got started, that I was to research the history and practices of Health Maintenance Organizations. I was very pleased by this intended assignment. I was certainly interested in the subject. But more specifically to my personal well being, I was concerned with how I might be perceived early on by my future co-workers. One's identity vis-a-vis the members of the organization to be studied, is an important issue. I wondered if they would think I was a spy or informer. At best, I thought that at the outset, most people would be confused as to my purpose at the health center. After all, it didn't take an anthropologist to

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151 figure out that members of this organization had not likely had much experience working with an anthropologist. I do believe that one thing everyone can relate to is organizational resources. It seemed to be able to answer the coming inevitable question of "what are you here" with a simple statement about studying other organizations who may be trying to compete for local clients. This response, I believed, would place me on everyone's "side." The assignment did not pan out, as the perceived competitive threat did not occur until much later. However, at first, I was given another resource related task. I am convinced that the nature of this job did help me make friends more easily. I was not only viewed as less threatening than might otherwise be the case, but as importantly, my role was clearly defined. Co-workers could categorize me. I therefore felt more comfortable sooner. I am also convinced, that this facilitated interpersonal familiarity. If advice may be offered at this juncture to fu,ture interns, it is that if at all possible, try and get posted into a situation where you can either help garner or protect organizational resources. In this capacity, you, via your role, will likely be viewed by co-workers as a helpful person. Ease of entry, can improve your chances of a more fulfilling research experience.

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152 Data Analysis I have been impressed by Jennifer C. Greene's (1994) discussion of contemporary evaluation program techniques. She says that "all qualitative approaches to program evaluation are distinguished by their preference for qualitative methods, including open-ended interviews, on-site observation, participant observation, and document review"(538). I would like to be included among those theorists and practitioners about whom she says, "these methods offer the greatest consonance with the interpreti vist perspective that frames and guides their work" ( 538). She reasonably argues that qualitative methods properly rely on the interactional, adaptive, and judgmental abilities of the very human social scientist. In this study I have employed two primary approaches which Greene identifies as major strategies for program evaluation. The terms she used in her analysis are "pragmatism" and "interpretivism." By the term "pragmatism," the author designates a strategy geared to appeal to program administrators. The preferred research methods here are eclectic and mixed but often include structured and unstructured surveys, questionnaires, interviews and observations. Pragmatism asks which parts of a program work well and which need improvement?

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153 It would also ask how effective a program is vis-a-vis the organization's stated goals. Also, it would seek to learn the effectiveness of a program with respect to the needs of the beneficiaries. Greene views "interpretivism'' as a strategy designed to inform program directors, staff, and beneficiaries. Featured qualitative methods include case studies, interviews, observations, and document review. A typical evaluation query of interpretivism might be, how the program is experienced by various stakeholders? (I note that "stakeholders'' is evaluation jargon for all groups and individuals who have a vested interest in the program being evaluated). From an anthropological perspective, these evaluation strategies are not necessarily distinct. There is a difference in constructing theory and the actual work of a lone anthropologist in an unfamiliar clinical environment. Still, these strategies are an interesting way to categorize. The author says that it is in this second strategy of interpretivism that the more traditional qualitative evaluative approaches have found a home. She notes that they share a common grounding in a value orientation that characteristically promotes pluralism in evaluation contexts. In this venue, the qualitative approaches seek to enhance policy understanding for stakeholders closest to the program. Therefore, they may engender popularly used channels to program improvement.

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154 For this particular study, both qualitative and quantitative data were reviewed together for the purpose of answering the primary research question. Again, this inquiry asks if community health centers offer quality health care to poor people. The interplay of institutional, neighborhood, city, state, and national health care mores and policy variables are presented as a fulcrum for evaluation. In trying to describe the steps used in the evaluation of the data, the researcher employed the following techniques. I coded the field notes to conform to emerging major thematic categories. I report that on-site, three of the research categories were evident to me at the very beginning of my internship. These categories include: 11accessibili ty, 11 "systemic cost effectiveness, 11 and "ethnically sensitive, neighborhood wise." At the same time, I admit that the category which came to be called "organizational birth, growth and nexus," only became obvious to me as I was immersed in the day to day internship experience. The formal survey instrument was pretested. It was also peer checked. In this case,.before the survey was formally administered, an anthropology doctoral candidate who happens to be African American and a resident of the neighborhood where this study was conducted, offered a constructive language critique. Further, the Executive Director of the health center as well as its manager, helped to make some of the questions more pointed. When the administration of the

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155 survey was completed, the researcher identified the instrument's percentages and frequencies. The researcher called upon a myriad of taught skills and formal techniques culled from intensive doctoral level study in applied anthropology. These techniques are designed to make meanings clearer to the investigator and hopefully the reader. The account of these follows in the next section entitled, "My Activities." Overall, I correlated all data in terms of the major research question. My Activities That which shall now be reported, largel y reflects the kind of on-site activities anthropologists have conducted now for several decades. The anthropologist works on behalf .of their assigned institution. We also work as staff to perform day to day duties. Fundamentally, we observe. Not to get too biblical or presumptuous here, but I always appreciated the perspective of "being in the world, but not of it." What follows is a truncated delineation of what "I did" during my internship experience. Writing Grant Proposals I helped the center write a number of lengthy grant proposals. In this regard, I was able to use my knowledge of

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156 various electronic data bases to merge the purpose and intent of granting institutions with the specific needs of this community health center. I contacted a number of such organizations and ultimately received opportunities to write for grants. Some of these opportunities were in the form of competitive bids. These were all first time opportunities. Succinctly, we did not win. However, through professional appearing grant requests and productive phone conversations, the center had gotten on the various germane granting 11 lists. 11 Powerful granting organizations knew to send EP (and did), new opportunities to receive appropriate specific purpose funds. A Patient Satisfaction Survey The Executive Director asked me to create and administer a patient satisfaction survey. I felt that this assignment was important because it would help the center to better understand the current opinions about the center held by its clients. Also, it could help the center identify perceived institutional problem areas as well as new health care concerns. This information would permit the health center to change and initiate policy in a community appropriate manner. I designed, pretested, distributed, and analyzed the survey. The instrument was backed up by six in-depth at home interviews with clients mutually selected by myself and the

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157 Head Nurse. The findings which were completed at a coincidentally convenient time, were used to help secure a continuing Federal grant. I also presented the survey results and my recommendations to the Board of Directors. Internist As Client A common practice among visiting anthropologists is to try and "go native." While this convention never fully changes the visitor's identity (except for the few who choose not to return) it does provide the anthropologist with a very different perspective on current events. In the case of the study at hand, I felt that if I was to adequately assess whether community health centers provided quality health care to its clients, it was to be extremely helpful to become one. I could not become a person with few economic options. This writer is middle class. However, exposing my body in this medical system would, I thought, give me a very rich and unforgettable experience. Therefore, I thought it instructive to have my annual check up at the CHC. At the time, I was also having abnormal symptoms. I so informed the internal medicine physician. Obviously, the "data" of my medical experience was tainted. The staff knew me and my reason for being there. We did all role play it very well as in, "Mr. Habin, the doctor will see you now." But I did have my experience to compare

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158 with the hundreds of others I observed going through the system. Therefore, my personal encounter was additionally informative. I also contrasted this experience.with slightly later private medical care. I didn't use both systems for the "good of science." I employed both because I was having symptoms and I was scared. Ultimately, I was able to compare both "patient outcome" and cost of the CHC versus a traditional "private" doctor-patient encounter. Social Service The priorities of my work moved me to want to assist the social service staff. Again, this opportunity to serve would offer me a different and informative perspective of community health and welfare problems. However, it was only on a very limited basis that I worked to assist clients in a social service capacity. The systemic reasons why my practice in this important area was less than expansive shall be made clear in a full discussion of the research findings. Marketing Efforts I worked with and contributed to the Committee on Public Relations and Fund Raising. In this capacity, I met on numerous occasions with a television professional who had

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159 previously produced some cable television videos for the center. Among our tasks was to create on-air patient information videos. The committee voted to create a series of 10-minute video presentations for the purpose of informing local civic groups of the center's presence. It was anticipated that the video efforts were to be expanded into a regular local cable television series. The committee was able to create informative brochures and gather a list of civic organizations (ie. the Rotary and Lions Clubs) which might be willing to hear our short informative presentation. The committee's initial purpose was not to ask for donations. Our purpose at this early phase, was to inform groups not traditionally aware of CHCs that we were alive and if needed, ready to help. Note Taking Among the attributes of note taking, I believe is personal centering. The technique is a constant reminder that you are on-site for a specific purpose. It is business. It also helps keep the anthropologist just a little bit detached from the day to day. Note taking also aids one's powers of observation. If you somehow know that you are going to so record something, you do observe events more carefully. The researcher's version of

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160 "accuracy" becomes critical when you know you will have to write it down. I kept three sets of detailed notes. My notebooks are entitled; "Internship-Day to Day," "Personal Feelings," and "Confidential." The first title indicated my daily running diary of CHC events. I usually recorded here several times a day. Personal Feelings was expanded nightly in residential privacy. I wrote in the Confidential notebook when staff members bared.their souls to me. These notes were cryptic by day, expanded upon at night. Also, "on the street" events such as people's HIV positive conditions were also so recorded. Interviews Interviews afford the researcher the opportunity to listen to informant's beliefs and opinions in response to a formalized series of prepared questions. What should emerge if this technique is performed with care, is depth and texture about the studied environment. The researcher has the chance to learn a great deal in a short time about people's world views. You may also be given new insight as to the dynamics of the studied environment. Hopefully, as a result of the interview process, the researcher's own observations should become ever so much more well informed. This study required that I interview many members of the medical staff including the Medical Director and the Head

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161 Nurse. I interviewed numerous office personnel. I also had an informative meeting with the center's landlord. I had the opportunity to question neighborhood clerics, business owners, and long time neighborhood private family physicians. On my last internship day, I interviewed the Executive Director. After leaving the center, I interviewed a former Executive Director. Drawing (Or At Least Doing My Best) A prize for best artistic rendering of any sort shall never be mine. However, I recognize that if given the time, drawing can be a wonderful technique for providing the researcher additional insight into the studied environment. Some of the variables which occurred to me while attempting this process are: is a particular room warm and inviting or more technological, are chairs and tables arranged to encourage group camaraderie or separateness, are offices designed for democratic access, or do particular categories of people prefer to fraternize in particular spaces? I found that as one begins to draw, each pictured area presents its own series of questions. The skilled researcher will likely set themselves up to learn a great deal about their environment when contemplating the respective answers. In studying the health center, I sketched every room in the facility. In this way, I believed I got closer still, to

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162 the client experience. I drew the outside as well. The idea here was to carefully compare the center's architecture with that of the neighborhood. I hoped to learn if the building was either inviting or perhaps, threatening many neighborhood residents. For this purpose too, I took numerous neighborhoodwalking tours based on information offered to me by helpful neighbors. Photography Anthropologists, encouraged by Margaret Mead and many others, have long used photography as part of ethnographic exploration. They had found that pictures reveal at least clues about the surface of a culture or institution. Photos also encourage additional exploration. As envisioned by Collier and Collier, "the goal of our efforts (photography), is to use the intelligence of photographic mapping to relate ethnographic considerations to the larger ecology" (1968:37). In the case of my internship project, slides helped me to recall the flow of activity which occurred at each photographic station. By means of this method, I also viewed areas such as the client intake window from the perspective of the person about to be served. A photograph may reveal, for example, if a familiar and comforting face welcomes the client into the health center's waiting room. It also shows if the

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163 intake person is easily physically accessible. There are multiple messages here. While some members of the staff were camera shy, I was permitted to choose from prepared slides featuring the personnel in action. I presently own 20 of these remembrances. These have been helpful as I recall both people's behavioral subtleties as well as the atmosphere at particular center work areas. Map Reading Map reading can prove a valuable research tool. It can help the visitor physically define the area of study. It can make the researcher gain a greater understanding of the influence of prominent environmental factors. Reading local maps will obviously inform you where locals consider the boundaries of their territory. The exercise may also visually represent how locals physically and perhaps psychologically, divide and therefore define themselves. For the purpose of this study I went to city hall to read maps and learn of the host city's racially-oriented housing demographics. Additionally, I superimposed the local zip codes and from the health center's master patient list, was able to surmise the areas in which the bulk of the center's clients lived. In this matter, I report that it was center policy not to provide me with random access to client names.

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164 Bearing Witness Again at city hall, I attended numerous raucous city council meetings concerning the issue of the alleged lack of community sensitivity of the police chief. I also attended related late night community meetings sponsored by numerous African American clergy. The issue was largely divisive along racial lines.. There were repercussions in the CHCs' neighborhood. There were repercussions in the CHC. Comparison of Official Documents with Research Analysis Obtaining an organization's official documentation can represent a helpful jumping off point to conducting comparative analysis. Official statements and organizational blueprints are visions of how organizations view themselves. The researcher may then use an organization's own words or pictures to set up comparative criteria. That is, one may see if the host's view of their own circumstance, matches the informed scholar's interpretation of their proposed variables. During my internship, I was given copies of the official organization mission statement and schematic representations of the center's organizational structure. I also have copies of all literature offered for public consumption. Financial

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165 records were too, readily made available. The highlights of these shall all be presented 1n the next chapter. An analytical discussion will follow. Experiencing the Neighborhood My additional activity included checking the bus routes to find that two lines stopped in front of the health center. I surmised that the center had been located in an excellent "trading route." I walked an entire bus route of many miles in a single day and noted the architecture. I rode the length of the other. In this endeavour, I watched and listened for hours. Note taking carne later. Assignment Specific Investigative Queries In attempting to assess whether CHCs provide quality health care for poor people, it is necessary to understand how these institutions are born, grow and become a part of and interact with their local environment. Further, it is helpful to examine their dynamic relationship with community groups, neighborhood as well as national organizations, and their place in the American health care schema. Community health centers are vulnerable to the whim and wisdom of federal policy planners. The financial and even culturally permissive largesse or not, of these officials,

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166 profoundly impacts the shape and substance of a CHC. An article by Constance Deroche (1987) exemplifies the adage of the "golden rule. Modifying it slightly, it says, "whoever controls the gold, makes the rules." There is to be sure, powerful environmental impact from above. Local institutions do, however, often have great leeway and ability to create inventive solutions within very broad macro system guidelines (DeWalt and Pelto 1985). They may also serve as laboratories which can shape even national debate. It may be that the on site experience invites the researcher into a ''natural laboratory." For example, a CHC may have to formulate a health care intervention which impacts behavior on such issues as lead based paint, dietary habit, or drug abuse. It is conceivable, that local institutional response to these and other problems can inform national policy. After I report on my particular internship experience, this possibility will be explored. I have decided to begin my study from the perspective of the low income client. It is the client after all, who needs help. It is in their interest that the institution was created. Therefore, I try to ask the question, "how might they perceive their community health center?" Included in this examination, is a consideration of initial provider availability, likely staying power, provider effectiveness, and the client's perception of the institution's credibility.

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167 I also feel it is necessary to investigate the additional medical resources available to these initial contact providers. Certainly, there are times when clients may need more sophisticated medical attention than a CMC can offer. CHCs as now configured, or even optimistically envisioned, would be unlikeiy, for example, to employ a brain surgeon. Similarly, one would not expect CHCs to have on premises, a magnetic resonance imagery machine. Therefore, it is important to study whether by means of first going to a CHC, a client can be efficiently helped to another phase of medical intervention. In addition to the medical milieu, it is important too, to investigate the financial resource base available to nonprofit community health care centers. In this regard, the majority of present CHC clients are not able to cover the costs of their own medical expenses. So early on, a health center mustrely on Medicaid and Medicare funding. Also, the federal government does provide grants to worthy institutions. Often too, private organizations offer specific purpose grants to health centers. County and city governments may also be sources of health center financial support. I plan to offer the health center where I interned as a recipient example. The nature of interorganizational relationships are an indicator of organizational strength and maturity. Beyond the boundaries of the CHC, lie the potential of association with other community organizations. These ties may prove important

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168 to institutional growth. Other associations may be found to be of a more competitive nature. A discussion of this outwardly oriented organizational behavior (Baker and O'Brien 1978) will be offered. I believe most medical professionals would consider a person's proclivity to obtain preventive health care to be beneficial. As such, it may be a wise strategy to consider an institutional intervention into the community to attempt to make preventive care locally habitual. In this regard, the strategic outcome would be enhanced by an understanding of how to most efficiently interact with neighborhood residents. This would likely mean, for example, in the case of an African American community, that health centers would do well to befriend local pastors and powerful church women (Greenbaum 1982, Hatch 1991, Peterson 1990). Other important studies have been cited (Pelto and Schensul 1987 and Vega et. al 1991), in regards to people of Puerto Rican descent and Mexican and Mexican-Americans, which demonstrate the wisdom and effectiveness of an ethnically knowledgeable health care intervention. Some of the activities in which I was engaged while at my internship, including meeting helpful respondents, were informed by these persuasive findings.

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169 Research Limitations Until now, I have delineated the included in my study of the Evelyn Perry Community Health Center. Here, I feel it appropriate to inform the reader what this study is not. Therefore, I remind that the comparative method is not used here. Comparative method is generally welcomed in anthropology and most other formal intellectual investigation. Yet in this study, I have only examined a single institution. I do hope that my particular experience will communicate cogent evidence for broad based policy change. There is another research limitation and it is me. I brought to the endeavour my own background, experiences, biases, misunderstandings, and foibles. The presence of the anthropologist must affect procedure and outcome. We are not value free. Therefore, another qualified researcher will achieve different results. Another person would be guided by their own world view. Their relationships with inforJ'!lants would be different. Their questions would be different too. Their study purpose would likely be at variance with my own. For the sake of some degree of regularity, I suggest that all one can do is be aware of their own theoretical compass, use methodology to the best of their ability, and try to sensitively "do good" for the respondents who have given of their time.

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170 I am aware that holism is an ideal. It would be wonderful indeed, if the visiting scholar could hear every conversation, know every nuance of institutional group speak, learn every respondent's feelings about what their body means to them, and even understand each person's relationship with their conceived deity. Well, that's not the way we humans work. The anthropologist cannot be everywhere. The reader must at some point trust that the trained scholar has done the best hejshe could. There must be a ceded confidence on the reader's part, that the anthropologist has understood and relayed enough so that new knowledge can be seriously considered at the academic table. Conclusion I personally gained invaluable insight by immersing myself in the business of the community health center. In this way, I was able to witness the dedication of staff first hand. I watched as the doctors relied on the social service staff for assistance. I was able to listen to the needs of the neighborhood. The extended internship allowed me to care about the human beings I have encountered. Due to my experience, I feel I can now make more informed judgements when recommending health care policy alternatives. I do admit that I have developed a bias. Any systemic change which I might suggest will be based on the criteria of making

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171 the lives of the people I've met more healthy and hopefully more fulfilled. In most cases, I was welcomed with open arms; this I will never forget. As an applied anthropologist, I have given careful consideration to research ethics as prescribed by the Society for Applied Anthropology (SFAA). In conformance with these principles of protecting human informants and their institutions, all relevant names and references shall be fictitious. Further, as regards the institutions involved in this study, I shall include no opinioned judgements.

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172 CHAPTER 5 FINDINGS Twenty years prior to the start of my internship, when I was just out of college, I got a job with an organization whose raison d'etre was to empower poor people. The office was located in Harlem in New York City. My colleagues for the most part were smart, tough, innovative and really gentle people who were themselves living on the economic edge. Working with them in that community, this freshly scrubbed white college grad learned lessons in camaraderie, respect, and ultimately, affection. Yet it had been twenty years since I had worked in a primarily African-American neighborhood. Among the disturbing headlines of the past two decades, there have been stories on urban riots, inter-cultural rage, an increase in the power of street gangs, and a seemingly declining value placed on human life. It seems that with the .passage of time, the streets had gotten meaner. The metaphor I had envisioned was of this middle aged white guy in a primarily African American neighborhood going up the many steps of a church, looking up in dread at a metal door knocker, and resignedly clanging the instrument against a huge metal door. I am trying to admit to you that I was

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173 nervous. No, I wasn't petrified or losing any sleep. But my hesitation was more than the ordinary new guy coming to work on his first day. And my first consideration was not about if I was going to obtain informative data about the community health center and its likely community service. My first thoughts were about whether I would simply be accepted. Organizational Birth, Growth, and Nexus The idea for a local community health center sprang from the hearts and minds of neighborhood clerics, politicians and private citizens. In 1984, it had become apparent to many, that low income people in this middle sized city in the southeastern United States, did not possess adequate health care options. Therefore, with the dominant urging of African American ministers, local people began to look for adequate health center space. According to the center's first director, none of the neighborhood's African American religious leaders were able or willing to come forward with an appropriate place. They were, however, instrumental in forming a committee to apply for federal funding. Specifically, they asked for a "Title III Section 330" grant in the amount of $200,000 dollars from the Department of Health and Human Services (HHS) Bureau of Health Care Delivery and Assistance (BHCDA) of the Public Health Service.

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174 At this time, a major Presbyterian Church had envisioned that part of their calling was to nourish a holistic health care movement. They viewed their mission as one of coming to the aid ofthe human spirit and body as well. The Presbyterian minister who happened to be white, was authorized to donate a large portion of his facility for the purpose of setting up a permanent community health care center. Again, according to the first director and a co-founder, this minister was not particularly liked by the majority of the local African American He was thought to be paternalistic. Yet it was he on behalf of his church who actually came forward with this most generous real estate offer. He also made certain that the church would provide the funds for the salary of one community outreach employee. The other leaders, apparently resentful, just sat on their hands. They did, however, list this Presbyterian church as the health center location on the federal grant application. It was to this address that the acceptance notification was mailed. The health center remains at the same location today. As the site issue was being settled, local Lutheran leaders met on the question of their mission of service to poor people. The head chaplain felt that theirs was a call to minister to the poor in the broadest possible way. They donated $30,000 to the emerging health center at a "rival" church. Preparations began for a 1985 opening.

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175 The center was to be named for a local African American heroine. It seems that in the previous two decades, a local educator, Evelyn Perry Ph.D.(pseudonym) rallied her community on issues of civil rights and community health care. Now in the 1990's, her picture adorns the waiting room and is one of the first things you notice as you enter the Evelyn Perry Community Health Care Center, Inc .. It is a pity she did not live to witness the birth. No births are easy. This was certainly true in the case of the Evelyn Perry (EP) Center. The first director reports that in the early days, many in the neighborhood didn't want the center to succeed. Many local residents didn't want the expected extra traffic. The former director believes that the fear of extra neighborhood traffic was a major reason that the city would only permit the center forty patients a day. While that was actually a generous numerical allowance, she made certain that city hall politicians removed the client cap in the center's second year. In that year too, she received a $40,000 dollar county grant. The response toward the center by many local clerics was generally underwhelming. Except for those on the Board of Directors, there were few other offers of tangible support. It was believed that a considerable number of African American ministers felt that the community health center belonged in a primarily African American attended church.

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176 EP established a mutually beneficial relationship with a local hospital. It seems that the hospital's clinic was not profitable. This large institution was only too pleased to refer their low income patients to the health center. I note that in the mid-1980's, the most frequent client health problems included: hypertension, diabetes, teen pregnancies, immunization of children, and a few AIDS cases. Also, the health care center pursued low income prenatal patients with the understanding that delivery would be at the hospital. A priority at EP was the employment of a full-time paid staff. The Board of Directors and the Executive Director felt a volunteer staff could not guarantee to the community a sense of permanence. Employed staff would also ensure predictable hours of operation. The story of how the head nurse was hired is illustrative. She was working a few blocks away in a nursing home. She saw an ad for the position in what she referred to as the neighborhood "negro" newspaper. A friend asked her if she had applied and she said she hadn't. But after some thought, she applied the next Monday. She met with the Director and the Medical Director "who was white." She was surprised that she was hired almost immediately. This was quite a step up for this nurse. At the time, she was a woman in her fifties and she had lived her entire life in this city. She said that as a girl, she remembered that "colored people" weren't allowed in this part of town.

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177 The nurse reported that in the health center early days, people who could no longer afford to see a private doctor would come in. Also, it seems that quite a few prenatal patients came over from the county health department. Apparently, it was not unusual there to have to wait all day to be seen. Word about EP spread quickly and the center began attracting a client base. A common route by which EP physicians arrive is through the National Health Service Corps (NHSC). During my internship, this was the case for the Medical Director and the Internal Medicine physician. In order to be eligible for said assistance, a community must be designated by the federal government as a Health Manpower Shortage Area (HMSA). This designation signifies that an area does not have sufficient available primary care resources to meet its existing need. The NHSC was established in 1971. Its purpose was to alleviate the provider shortages in the identified areas. Under the plan, physicians, nurses, dentists and other professionals who needed to pay off their formal schooling training debt, could be assigned to one of the government's chosen areas. They would then be required for a period of three years to work off their government loan in their assigned institution. Federal statistics indicate that a higher proportion of minority physicians practice in primary care fields and minority physicians are twice as likely to practice in underserved areas.

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178 It is important to become acquainted with how an institution represents itself to its potential client base. One efficient way is to become familiar with THE brochure or the ubiquitous reading material always on display in the center's client waiting room. The brochure is entitled "What Makes Us Unique? Amid numerous photographs 'featuring multi-ethnic health care providers and clients, it proceeds to delineate available center services. Some of the current program highlights include: -provide comprehensive health care at low cost -serve all men, women, and children -convenient hours of operation including 4 evenings and Saturdays -the only county health care facility serving the low income community during evenings and weekends with a full range of pediatric, prenatal, and family medicine -For patients ineligible for public assistance. or unable to pay full costs, the center provides the only viable full time alternative to hospital emergency rooms -over 75 adult hypertension and diabetic patients treated each week -special programs conducted with local churches and synagogues include flu shots, cholesterol screening and blood pressure checks -waiting room time is generally kept to under 20 minutes

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179 -patients have direct access to top management for all complaints -all staff are required to have contact with patients -center is managed as a business with standard business personnel, management, and fiscal policies -administrative costs are kept below fifteen percent -All files other than patient records and personnel files are open for inspection -Board of Directors regularly reviews management decisions -Special attention is given to Medicaid and Medicare registration -Costs are contained through cooperative programs with other agencies Perhaps the most obvious means of institutional representation to its client base is physical appearance. I shall try by word to give you the feel of The Evelyn Perry Health Center. Standing across the very busy avenue from the center, one first notices the institution' s sign implanted on the grass. Looking to the right or to the front yard, you can see behind a short metal fence amidst trees and a child worn grass field, the top of the metal play slide. Upon examination of this recreational vehicle, one can discern that it had seen better days. You next notice a long covered walkway which leads to the door. The door opens on the left, but you observe that a large

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180 white house stands behind the corridor. The driveway and then a tree lined parking lot are on the edifice's left. Back of the center structure and to the right stands a dignified looking white church steeple. This eclectic mix is contained in an approximately two and a half acre "campus. As you cross the street you notice that the white house like structure could do with a good coat of paint. The parking lot pavement is rather cracked. It also contains several light poles to serve evening visitors. These resemble stadium lighting. The overall outside impression then is that of a rather large white house. As I have described my observations of neighborhood architecture, it is my belief that EP visually fits into the community rather nicely. It is not an intimidating "medical building." That's good because some interviewees told me they were scared of doctors. But I think at least as importantly, the building resembles its environs. It just seems that it and perhaps its visitors feel at home here. Thirteen chairs arranged in the shape of a capital U, pretty much take up most of the space in the waiting room. On the wall behind the entrance there is a poster of a woman and under her likeness a caption reads, "pregnant, don't use drugs." Hanging on the left wall is a framed color photo of Dr. Evelyn Perry.

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181 On the far wall, a clock is perched above a bulletin board, home to a seasonably changeable display. In November, cut out turkeys would come to visit. In January, before and after the 17th, drawings and photos of Dr. Martin Luther. King adorned the room. February was Washington and Lincoln month. The door to enter the interior of the center was on the right or more geometrically, it was diagonally across the waiting room from the front door. To its right was a magazine table, a poster for the local taxi company, and the sliding glass desk/partition where the receptionist and clerical personal were ensconced. Directly above the glass was the sign, "Payment Is Required At Time of Service." To the right of the sign was a 19" television. The usual fare was Geraldo, Donahue, and Oprah. The afternoon often featured Fox Kids Club Cartoons. As you entered the interior, you walked into a hall whose main feature to the left, was the head nurse's office. As you proceed down the hall, you notice a bulletin board just loaded with baby pictures. It seems that these infant's mothers had prenatal care at the center and were delivered at the nearby hospital. These beauty's had returned as center clients. Next on the left came a scale, and then the first of eight examination rooms. Between these rooms, several Matisse lithographs brightened the corridors. Nearing the back wall on the left hand side, was the laboratory. On the right was

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182 the washroom. On the back wall, at the end of the hall, was the social service office. After being buzzed in from the waiting room to the inner corridor, if you knew to jog left instead of making the obvious right, you found yet another door. Upon opening it, you would see a long staircase. Before proceeding up the stairs, you notice a locked door. This was reserved for the church and staff bathroom. To the right was the church office. Going up the 10 stairs, the visitor faced three more closed doors. If you opened the door on the right, you entered a multi-purpose facility. First, it served as the office of the director of medical records. It also served as the center's lunch room. The room's center featured a combination work table and communal lunch table. The walls were lined with manilla folders. To the right of the door stood the refrigerator and a microwave oven was perched upon a cabinet. Near the back of this room was the medical records director's desk and computer. On the back wall was still another door. This back wall was in fact a half wall with its top made of glass. Inside this office were two large desks. The desk on the left was used by many of the physicians. It was a place where they could read their journals, eat, or just get away from it all. The desk with (amidst the children's finger paint) the glass view of the lunch room, was where a particular intern was generally ensconced.

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183 Back outside, the door on the left opened to the administrative offices. The desk facing the intruder belonged to the center manager. The back desk of this office was that of the Financial Director. The impression the visitor to this room received was of a high tech laboratory with ubiquitous computers and printers whirring, beeping, flashing and printing out. The view out of the large bay windows was of trees and the parking lot. The very back office was that of the Executive Director. The door opened to a circular mini conference table. The office was simply appointed. It included a number of well stocked book shelves, a large desk (topped by a computer) and numerous affectionate looking family photographs. The office was quite functional, occasionally paper messy and in no way approaching the realm of what one might think of as typical executive luxury. The corner view was also of trees and the parking lot. Back outside at the top of the stairs, you noticed a third door option. If you made a left and walked about 10-steps (passing a maintenance closet) you came to the third door. This room was simply a large cavernous space. It could easily hold 100 people. It was owned by the church. EP used it for Board of Director meetings, staff parties, and classroom space. I was most anxious to learn how clients came to EP. Therefore, on a client questionnaire which I designed,

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184 implemented and reported upon, I asked 138 waiting room visitors "how did you hear about EP Center?" It was an open ended question. They answered in the following manner. Obviously, word of mouth via friends and family is really helpful to the center. Also, it seems that the state human resources agency is pleased to send clients to the EP Center. Local hospitals also seem willing to send their patients to EP for follow up care. The county health department is also sending EP low income clients. Table 15. How Clients Have Heard About the EP Center Friends and Family 55% State Health Services Department 14% Hospital Patient 14% County Health Department 9 % Newspaper 4 % Hospital ER 2 % Free Clinic 1 % Other 1 % I will now explain the medical routes available to a client when they walk in the EP door. First, of course, the client will see a physician. Often, they will continue with this client-physician relationship. This is so because the

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185 doctors are hired and this service is their permanent employment. Also, a person seeking help for a particular kind of malady, or a person in a particular age category (infants or seniors) would likely continue, with the pediatrician or internal medicine physician. Many tests can be administered in the EP laboratory. But if a staff physician decides that additional tests are required, the clien t can be sent to the local hospital. As EP has a relationship with the hospital (maternity, for example), and the patient is obviously low income, fees for this servic e tend to be modest. If the client requires a specialist, the social service counselor will set up the appointment. In many cases, the counselor will ask specialists what they charge for a service. The client is generally sent to the doctor whose fees are most reasonable. Sometimes, free service is.negotiated. In one of the staff interviews I conducted, a physician told me that a low income client would be much more likely to have extensive tests coming from EP, rather than if the same person were under the care of a private practice physician. He believed many doctors would hesitate to schedule expensive tests because of their patient's financial vulnerability. He

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186 finds it ironic that testing capability is the very opposite of what one might expect from the two different medical paths. If a client needs a prescription, the center encourages them to go to a particular neighborhood pharmacy. This establishment located about two miles from EP, services many of the center's clients. Because of the volume of customers EP sends to this drug store, the pharmaceutical prices are extremely competitive. Also in the domain of pharmaceutical prices, drug company reps are very helpful in dropping off large supplies of free samples. Once again, volume buying power does make a difference. The EP medical staff includes a physician with hospital admission privileges. The center in very short order, can have a client admitted to the local hospital. After they return from their visit, with EP. We now they generally resume their relationship turn to the financial data which will indicate how this CHC is fiscally supported. We can here discern the very great degree of federal support given to EP. City and county succor is helpful, and donations are too. But without federal grants and program support, this health center would be resource starved. Table 16 provides the reader with specific evidence.

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187 Table 16. Statement of Support and Revenue and Expenses Support and Revenue 1991 1990 Federal Grant-Title v $ 390,574 328,989 County 10,774 12,500 City 43,691 11,793 In-kind 25,200 18,240 Donations 15,620 53,936 Revenue: Patients Fees* 836,777 533,994 Misc. Income 20,451 16,184 Total Support & Revenue 1,343,087 975,636 Less: Contractual Allowances** 289,781 296,589 Net Revenue 1,053,306 679,047 Total Expenses 976,084 649,379 Total Revenue Over Expenses 77,222 29,668 *Note: A significant portion of patient fees are from services provided to patients covered by the Medicaid and Medicare programs. The health center receives payment for patient services at predetermined rates based on patient diagnosis and allowable cost. **Contractual allowances include the difference between these standard rates and the amounts paid under these programs.

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188 Let us now turn our attention to the various means by which EP gets paid for its services. I present the data for a typical month during my tenure, in this case, March Again from this table, we can see the extent of government support. By adding the three categories of government program payment we find that nearly sixty two percent of the clients are helped by policy intervention. Table 17. Total Encounters by Pay Type Medicaid 56. 5 % Self Pay* 36.6% Medicare/Medicaid 3.1% Med icare 2.3% Insurance 1. 4 % Other 0 *Note: The self pay category includes a sliding scale of payment based on the client's ability to pay. The scale is 20-40-60-80-100 percent of the charge per service. During my internship, I was offered two EP organization charts. The first one was designed months before I started. The second was created about six months into my assignment. As you can see from figure 1, the Board of Directors occupies the top rung of the center. The board is made up of

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189 THE EVELYN PERRY COMMUNITY HEALTH CARE CENTER (FIRST VERSION) BOARD OF DIRECTORS EXECUTIVE [ADMINISTRATIVE ASSISTANT] DIRECTOR rl DIRECTOR SOCIAL SERVICES E.P MANAGER PHYSICIANS (3) I I OUTREACH OftlC E S TAFF (6) I CONTRACT PHYSICIANS (10 FROM 2 HOSPITALS) PEDIATRIC NURSE PRACTITIONER I I L MEDICAL ASSIS TANTS ( 6) Figure 1. The Official organizational Chart of 'ty Health care Center at 1nterns lP s Perry Comrnunl inception.

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r--I 4 190 THE EVELYN PERRY COMMUNITY HEALTH CARE CENTER (SECOND VERSION) BOARD OF DIRECTORS I EXECUTIVE DIRECTOR T 1 l E.P. MANAGER MEDICAL DIRECTOR f-. FINANCE DIRECTOR l E.P. PHYSICIANS (3) FRONT OFFICE STAFF (6) HEAD NURSE ....... SOCIAL WORK STAFF rl PEDIA'I 'RIC NURSE PRACTITIONER 1 .... ,..._.; MEDICAL ASSISTANTS (6) I Figure 2. The Second Official organizational Chart. Designed approximately six months after the start of the internship assignment. In this second schematic, the aforementioned contract physicians are not represented. The relationships themselves did not change. In figure 2, however, they were not formally rendered as part of the permanent full time EP staff. Coincidentally, this representation more closely conforms to my internship experience.

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191 local residents. Among the members are clerics, doctors, lawyers and nurses. The Board Chair is also on the board of a large local hospital. Almost all board members receive EP medical care. The Executive Director serves at the pleasure of the board. Among his duties is the responsibility of providing monthly reports to the board. He is the daily on site administrator. He is also charged with grant application responsibilities. He makes the overall decisions about staff size and their pay. He decides too, in which areas the center's resources will be spent. He is also a public relations spokesperson to local civic groups as well as to several layers of federal officials. Simply stated, he's the hands-on boss. Below the level of Executive Director, is the Finance Director. At the time of the first chart, a vacant position existed for Administrative Assistant. The Finance Director frequently reports center financial conditions to the Executive Director. He is also charged with making monthly reports to the board. The next level includes the Medical Director, the Social Services person, and the EP manager. All report to the Executive Director. Three staff physicians report to the Medical Director. Contract physicians from the local hospital do as well. The contract physicians tend to serve on Saturday. The pediatric

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192 nurse practitioner also reports to and consults daily with the Medical Director. In Figure 1, the Head Nurse is placed below the pediatric nurse practitioner. But she reports to the Medical Director. The Head Nurse is in charge of six Medical Assistants. In the first chart too, the social service person reports to the Executive Director. An outreach person reports to the social services employee. The schematic indicates that the front office staff reports to the center manager. At the time, there were six such employees. They are charged with greeting the public, and making appointments. They also answer the health center phones and often, all six telephone lines are simultaneously blinking. It can get hectic. There are three changes in the figure 2 newer diagram. First, the EP office manager has been elevated to the level of the Finance Director. Secondly, the schematic shows that the pediatric nurse practitioner reports to both the Head Nurse and the Medical Director. The third change indicates that the social service employees now report to the center's manager rather than to the Executive Director. When there was a personnel change, the person to whom the social services employee reports changed as well. A final observation is that though the practice of hiring contract physicians from local hospitals continued, they are not represented in figure 2. When comparing the organizational chart with actual

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193 personnel behavior, one finds the two rather similar. This is true because I believe the hierarchy is respected in this organization. Additionally, office geography or where one works bears greatly on with whom an individual converses. The Executive Director, for example, has ongoing contact with the Center Manager and the Finance Director. As described, these three have adjoining work space. This configuration makes obvious organizational logistical sense. These people have a daily need to talk. Proximity and work space layout play a very large role in keeping top administrative staff shielded from the active health center level. Recall that I mentioned that as one enters the health care area from the waiting room, that there was another door on the left. Again, that door leads to the stair case and the administrative offices. But when you do enter the inner sanctum, the visitor has a tendency to look right rather than left. The right is where the health care activity is. Also, long term clients know the direction toward which they will be examined. The effect is like camouflage. The appearance acts as a visual buffer leaving the administration free to work. Contact between the Executive Director and the front office staff is infrequent. There is obvious name recognition and friendly salutation, but it could not be described as "warm and fuzzy." The schematic has utility too, in that the center manager does have frequent front office contact. Also, the Head Nurse has

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194 a close relationship with the Medical Assistants. I note that the Head Nurse often acted as a mother-confessor to her young charges. She would often listen patiently to their problems which included those of an out of office personal nature. Not surprisingly, staff at the same level of responsibility had ongoing contact. For example, early in my internship, I attended an organizational party. I didn't yet know many names but I noticed that all of the women dressed in peach colored tops really rather stayed together. I was to later learn that these were the medical assistants. Certainly too, front office staff mingled in their area of the room. The 28 full time staff members behaved as if observing the hierarchy. Nexus The next few instances offer situational examples of the relationship between the health center and its environs. How a particular medical assistant seven-year employee came to EP is illustrative. When the woman finished high school, she decided to take one more year and get a diploma as a medical records specialist. When she graduated, her mother had been working at the local chapter of the American Association of Retired Persons. The center was considering hiring an older person and her mother had heard about the EP job opening. I asked the

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195 young woman why she then applied? She looked at me as if I were crazy and said "because I needed a job!" The center has been helpful in this way as it hires local people. Even some of the physicians are permanently local. A particular restaurant owner has sent clients to EP. Mr. Jackson (pseudonym) is famous for his "Jackson Burgers," fried chicken, and my personal favorite, the mullet sandwich with everything on it. He has been in the neighborhood for years, and has many local contacts. People come to Jackson's to eat and hang out. He permits a permanent EP poster on his bulletin board. He also tells people who are in some way hurting to come. Also, each year he hosts a retirement party. Not his own. Instead he hosts a party for everyone in the neighborhood who he hears is retiring. EP is part of his message. Parenthetically, some EP staff members make a "Jackson run" nearly every week. Pastor "Robert Coleman's" Baptist church is located 4-miles west of the center. He said people talk about their physical and emotional problems with him all the time. The Pastor said people in the neighborhood are hurting because of "occupational problems and physical needs.'' Specifically, he listed arthritis, high blood pressure, hypertension, depression, and exhaustion as his parishioner's most common maladies. He surprised me when he said most of his Sunday faithful had not heard of EP. He suggested that the center concentrate

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196 on one part of the neighborhood and work it hard. He was open to the idea of a member of EP staff addressing the congregation on some Sunday morning. While EP staff would not be allowed to speak during the regular sermon, he did offer the center the podium during the post sermon "announcement time." The center would also be permitted to hand out literature. He would also allow free blood pressure checks in the church parking lot. That is good news as the Head Nurse had informed me that in the early days of the center, she did go to church parking lots with free blood pressure checks. She found many ministers unenthusiastic about the program and they really didn't encourage parishioner participation. The program was discontinued. Perhaps this stance had something to do with the many hurt feelings going back to the center's founding. I am pleased to report that in m y interviews with clerics, the feelings have obviously softened and improved. In one particular case, a 70 year old man needed to see a dentist as his teeth were literally rotting away. He also needed to see an eye specialist. That is what the EP social service employee, Ms. Jennings, was told by the examining physician. She very rapidly got on the phone and got the client both appointments. She also asked the right questions of the client as he would need medicaid paid taxi's to get him t o his appointments.

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197 A busy physician referral day for Ms. Jennings is meeting with 10 clients. An average meeting takes about 10-minutes. That is her main job. Additionally, she gets her clients needed services. A common situation would .be getting medicaid for a newly pregnant client. She is well versed in state and federal agency bureaucratic jargon. She knows whom to call for many kinds of aid. In this manner she was able to obtain free underwear for one mother's two young children. Only occasionally was she busy enough to permit me to help. One such incident occurred when a client needed an appointment at a local hospital. She was to have a spinal CATscan. I told the hospital appointment person that the client had no money and was on Medicaid. I was able to get her an appointment for the following week. It was a great feeling. In order to gain invaluable knowledge of neighborhood medical maladies, let us examine the germane data. Table 18. EP Client Care by Medical Practice Category Obstetric Pediatric Internal Medicine Family Practice Other 35% 23% 19% 16% 7 %

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198 The table demonstrates that in this particular neighborhood, issues of women and children's health are extremely important. To answer this need, the center sponsors free on-site prenatal classes. Fortunately, many of the expectant mothers become permanent EP clients. The federally funded free classes have become an important means of obtaining new client confidence and trust. On the subject of local disease characteristics, I recall that the director of the county health department attended one of the monthly EP Board of Directors meetings. He listed the local rise in community health problems in the following manner: Tuberculosis, Influenza, Hepatitis and the requirement of childhood immunization. This information was to prov e immediately poignant. It seems that the health department was about to cap the number of its allowable patients. The county director said that they "weren't going out of business," but they simply could no longer care for an ever expanding patient population. Therefore, in cooperation with the county health department, EP was going to have to rapidly add to its client base. In this regard, the director and the EP Executive Director, discussed an interesting intervention. The two decided that "training" hospital emergency room doctors to recommend EP to patients, would achieve some of the needed results. As my internship progressed, I noticed that this theme of interorganizational cooperation was accelerating. For

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199 example, the Executive Director told me EP must align itself with other agencies in future grant proposals. He believed that the more agencies EP involved, the greater the chance for granting success. He said that unfortunately, EP would lose some control of the project. But he felt that the tradeoff was institutionally beneficial. An example of this cooperation was to come in the form of an HIV care grant. EP along with a local university, and a neighborhooq drug rehabilitation agency applied to the federal government for an HIV client program. It was to be located across the street from EP. EP was to solicit clients and provide the medical professionals. The consortium won the grant. During my internship, the HIV center was established. However, the grant stipulated a cap of only 350 clients. Also, the target population for this help was to be African American males. This last requirement proved to be a problem. It seems in the first few months the population which was attracted to the new center was white males. Also, in the main, these men were not neighborhood people. Rather, many lived in a city 50-miles away. This startling situation apparently came about because a few men who lived in a group home had heard of the center. They then informed their friends. This was so despite the fact that the center had a "soft" opening. In other words, neither EP nor the other consortium members really announced the opening. The reason for the lack of announcement was due

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200 to the small client population the center was permitted to help. EP hired an outreach person to try to get neighborhood people to be tested for HIV. She was to work at night and go to the known neighborhood hangouts. She was to hand out free condoms and solicit clients. She learned that local people were embarrassed about coming to the center. Interestingly, the 50-mile travellers were also confronting the issue of anonymity. Therefore, EP program administrators thought it possible that the local neighborhood people were getting their HIV symptoms addressed out of county. The outreach person worked very hard. This former gang member had entre in places where most outsiders wouldn't venture. She was successful at bringing clients to the new facility. By all accounts, she was doing an outstanding job. Yet at the time my internship ended, the number of her clients could not keep up with the word of mouth out of city clientele. EP cooperated with numerous neighborhood organizations. As mentioned, the center had an arrangement with a pharmacy located about two miles away. Because of the center's patient volume, it could negotiate prescription prices for its low income clientele. EP, with the help of a local drug rehabilitation organization, co-founded another health center located right

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201 in what was considered the toughest housing project in the city. It was open two days a week. The thinking was that if some clients wouldn't come to EP, the health center would go to them. Adjacent to the center, and a co-renter ($1.00 per year) of church property, is a volunteer agency which mainly supplies free clothing to children of low income homes. During the 1991-1992 period of my internship, the agency outfitted nearly 1, 700 children. They also paid for urgently needed medicine for 140 people. The agency further helped nearly 450 families with rent and utility payments. Quite naturally, there is frequent interorganizational client recommendations between the agency and EP. I recall helpful interorganizational connections of a different sort. As EP does buy in bulk quantity, the local representatives of the various pharmaceutical companies would drop by, tout their products to the physicians and leave a good supply of needed free samples. Beyond this, a very nice congenial tradition existed at the center. It seems that every two weeks, a different pharmaceutical representative would drop by at noon and offer hot lunch for 28-hungry staff people. A typical menu might include fresh pasta, garlic bread and salad from The Olive Garden Restaurant. The quantity was generally gargantuan and despite staff' s best efforts, there would always be left overs. Much food was left for the evening

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202 shift people. But what was wonderful too, was that employees were encouraged to take the food home to their children. In a variation on the theme of community organizational relationships I report that the EP administration. was concerned about client encroachments coming from would-be Health Maintenance Organizations. That threat (or at least it was treated as such,) emerged during the latter days of my internship. In response, EP developed literature comparing its service capabilities to that of an HMO which I'll call Health Care Plus (HCP). The title of the two-paged EP document is, "Some Questions and Answers About Health Care Providers. The following quotes represent a few of the telling comparisons: Who runs the EP Center? The EP .Center is a nonprofit community based medical organization. Its Board of Directors are all county residents, and most are patients at the center. HCP on the other hand, is a for-profit company located hundreds of miles away. No HCP Directors live in this county. How can I be sure I will receive appropriate treatment? The EP Center will authorize a l l treatment necessary, at our center, at hospitals, or with specialists. We are in business only to provide care. HCP, on the other hand, receives money from a state agency whether or not they provide care; this gives them an incentive not to treat you, because then they do not have to pay the doctors. What if I have a problem when the Center is closed? All EP medical and executive staff carry pagers at all times. If your call is not answered within half an hour, the doctor responsible is disciplined by the E xecutive Director. When you reach an EP doctor at night or during the weekend, the doctor will authorize whatever treatment he or she feels is necessary, including hospital visits, without

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203 regard to cost. HCP needs to avoid such costs if it is to make a profit, so you may be less likely to get appropriate referrals during off hours. These are obviously two differently organized providers in the same profession. It appears that the Evelyn Perry Health Center and HCP will not be forming alliances any time soon. Instead, they are likely to compete. The Evelyn Perry Community Health Center has experienced quantifiable growth. In 1991, for example, the center had nearly 18,500.encounters. That figure represents an almost sixteen percent increase over the 1990 total. More than this, the organization has also grown. In fact, in the early weeks of the internship, I was frequently commuting between EP and a brand new health center which the organization opened in the northern region of the county. The creation of this new center is a study in symbiosis. By that I mean, the local hospital in north county financed the entire construction of the facility. This contribution represented many hundreds of thousands of dollars. In return, the new health center was to service the hospital's low income patients. The schematic shape of the CHC was changing. Originally, The Evelyn Perry Health Care Center Inc. was the corporate name. However, with the opening of the hospital financed health center, and the joint founding (with the drug rehabilitation agency) of the health center in the city project, as well as the partnership created HIV center, a new

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204 umbrella name became necessary. At a meeting of the Board of Directors, the new umbrella name was voted upon. It was to be Pearce County Community Health Centers, Inc. (pseudonym) Evelyn Perry was to be one of four community health centers in the county organization. Additionally, as my internship was drawing to an end, another community health center in east county was being planned. But with this structure in mind, I remind the reader that this particular study was only of The Evelyn Perry Community Health Center. Accessibility It will come as no surprise that a majority of EP's clients come from surrounding environs. By examining the county 1990 census employing 1989 data, I find that twenty percent of the client base comes from the center's particular census tract. I surmised this information by comparing client zip code registration with the census tract configuration. The adjoining western tract provides another twenty t .hree percent of the client population. Going west again (a distance of about two miles) I find that eleven percent of EP' s clients live there. Recall the Pastor who said that his parishioners had not heard of EP. Interestingly, in the more western tract where his Baptist Church is located, I learned that only four percent of EP cliental come from his vicinity. His opinion was largely accurate.

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205 The tract to the north of the health center contributed another seven percent of the client population. In all, considering all adjoining census tracts, I learn that nearly sixty six percent of the clients came from the "local" area. The other one-third, are from scattered county and non-county communities. I now examine the census tracts by median household income. The tract in which EP is located has a median household income of nearly $16,500. This rank is in the bottom twenty five percent of county tract median household incomes. Further, I find that forty six percent of the tract's residents earn less than $15,000 a year. Five percent earn over $50,000. The adjoining western tract lists median household annual income of just over $15,000. Therefore, nearly half of the households earn less than $15,000 annually. Seven percent earn over $50,000. The other adjoining census tracts also rank below most other county median income tracts. For example, four miles west, in the tract where the aforementioned Baptist Minister's church is located, the median household income is around $16,500. To the east of the health center, the median annual household income is about $13,250. By way of comparison, I find that the more affluent tracts report annual median household incomes in the high thirties and low forties. The EP family practice physician told me that a typical

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206 EP client is someone who can't afford care elsewhere. The doctor believes that the recession of 1991-1992 had increased the center's client population. He feels that many who come to the center used to have jobs but were flushed out due to the recession. Their savings are depleted. Others, he says, are working in jobs which do not provide health insurance coverage. For many who lost their jobs, these are new financial circumstances. Some of his clients have expressed anger and embarrassment at their situation. He says that these clients are in need of reassurance when they come in. He notes that those feelings of insecurity vanish after they have established a relationship with the physician. They feel better when they know that in the area of family practice, "I'm the one to take care of them." The internal medicine physician believes that nearly half of his patients used to see private doctors when they were in crises. He confirms that many are now unemployed due to the recession. Others are in jobs which don't offer major medical insurance. He says that he has often heard client anger at the system that brought them to EP. In an in-horne interview a 50-year-old African American woman told me that at first, she felt badly about having to come to EP. She described herself as "a very proud lady," and that she was used to working. She said that she really felt depressed about not being able to afford her private doctor

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207 when she was laid off. She was discouraged until she met EP's internal medicine physician. The doctor soon noticed a condition in her hands which was she said, quite rare. She was impressed with his correct diagnosis. She said he restored her confidence. The woman confided, "a doctor is like a minister, you have to have faith in him." There are a variety of means by which clients first came to EP. For example, one client told me that the family practice clinic across the street from a local hospital doesn't take Medicaid. So, she started coming to EP. On the other hand, another woman I interviewed said that she was making too much money to be seen at the county health department and they suggested EP. More typical is the person whose physician didn't take either Medicaid or Medicare. For example, I was in the home of an elderly gentleman. He offered that because of the accompanying paper work, his old doctor didn't take Medicare patients. He said he came to the center because it accepts Medicare clients. He said too, that because EP prices were reasonable, he could comfortably afford the required Medicare co-payment. A 28-year old woman told me she appreciates that EP is very flexible and nice to her when she's low on funds. She does work but her salary is low. The health center has carried her debt for many weeks on numerous occasions. She told me that she always pays eventually but sometimes she "just

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208 doesn't have it." She knows that EP is aware of her financial condition and is grateful for the center's understanding. Although I learned that community confidence in the center is generally very high, not all encounters are successful. In this regard, one afternoon I was in the waiting room (I was there quite often) and a woman in her early thirties came in. Apparently, she had almost no money. She was informed that a physical examination would cost $6.50. She became very upset. She was permitted inside to call her case worker. The discussion between the woman, her case worker and EP concluded that in the future, she would have to come to the center with a notarized letter from her family stating that she was unemployed. Otherwise, she would have to pay at maximum rate. Nevertheless, on this particular visit, she was given a medical physical. She was permitted to pay $6.50. But she was not happy. She had thought the center offered free care. Free care EP is discouraged. But I will say that I have seen people with absolutely no money cared for. Despite the public discouragement, I witnessed very few people actually turned away. The center's manager told me that another reason clients are attracted to EP is because of the personal attention given to them by staff physicians. She reminded me that center physicians are not paid on a fee for service basis. They are

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209 instead, salaried employees. They could, she said, take their time with clients. I wanted to test this opinion. In this regard, I enlisted the help of both EP clients and staff. For example, one of the Head Nurse's previous positions was as nurse for a private physician. She had worked for him for fourteen years. The Head Nurse validated the center manager's opinion. She believed that the center doctors spend more time with clients than even private practice physicians. She said "that is why we are liked." A physician told me that what he liked best about working in the health center was that he had the "freedom to practice medicine." He felt fortunate not to have to worry about the paper work and other responsibilities which come with a private practice. He said he appreciated that he could spend more of his day helping people. He did say, too, that sometimes his inability to control scheduling can be a problem. There have been days, he said, when front office staff scheduled too many of his patients. But he said that overall, the trade off of lack of scheduling power versus the ability to help more people was overwhelmingly worth it. A client I interviewed in her horne seemed to represent majority opinion. She reported that her center physician understood her rare condition. He was caring and took all the time she needed. In fact, on her last EP visit, her doctor

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210 wrote her a note to be sent to the local electric power company. The note asked the company not to increase her electric bill. It said she could not afford another rate raise and that air conditioning was crucial to her condition. I recall that center physicians were pretty savvy when it carne to helping clients solve problems which required a social service fix. Perhaps this client may have been a little too enthusiastic . It seems that "her" internal medicine physician had recently announced that he was leaving EP. His three year stint as a National Service Corps doctor was up. The physician had told me that he really wanted to stay but his wife who was living in the midwest, was unable to land a comparable local job. Therefore, he was forced to move to his wife's midwestern city. The patient in question arrived at EP with a cake shortly after our in horne interview. The frosting said "Goodbye Doctor From Your Hopeless Patient." Interestingly, her last question to me as I was leaving her horne was "I hear the new doctor is Vietnamese (really Chinese American finishing his residency at Cal-Berkeley). Does he speak English? One might discern from her question a bit a consternation concerning her future client-physician relationship. Another client I interviewed said he carne to EP to see "the diabetes man." I had heard that moniker on a number of occasions. Apparently the center' s internal medicine physician

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211 was particularly adept at working with many of the community's diabetics. That phrase offered me additional evidence that clients with a particular malady, would almost always see their same physician. This proved to be reassuring to the center's relatively small senior population. It also reflected a concern harbored by the center's general clientele. In this regard, the pediatric nurse practitioner told me that at the county health department, patients were very unlikely to see the same physician each visit. It is in this context that I relate that many first time EP clients ask how many doctors they have and will they see the same doctor next time? In most circumstances, the client will hear an accurate affirmative response. I was interested in learning how long it might take a client to see one of the doctors from the time they called for an appointment. The Executive Director informed me that when the center was really busy, it could take up to two weeks to schedule an appointment. This was particularly true in August/September during school mandated inoculation time . This was also the time period when the center offered seniors free flu shots. During most times of the year, however, my own observations demonstrated that most people could make an appointment three or four working days in advance. I will now return to discussing the look and feel of the center. I described that the outside of the building really looked like a large relatively well kept neighborhood

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212 connected home. But I also wish to describe the place where the practice of medicine was conducted. As a client, as well as an observer, I took my place on the examination table in one of the eight so appointed rooms. What I remember feeling was very alone. The room was stark. There was nothing gay about it. The walls were bare. Medical equipment was surrounding me. I did not feel either relaxed or welcome. I wanted to leave. It was an examination room which you reader have already experienced. It felt like an examination room in any doctor's office. But at that time of vulnerability, I was hoping for something more. Until the reassuring words of the physician, I felt alone and afraid. Surely, these rooms could be aesthetically improved. A physician told me that at times during the day, the center over books. The practice apparently doesn't occur at night. It was the opinion of the doctor and apparently the scheduling staff, that the evening clients are more responsible about keeping appointments. I'm told that because most of the evening clients work, they are considered more responsible about showing up for a scheduled appointment. When every day patient comes as planned, the waiting room can get pretty hectic. For example, one client told me of her particular irritation. One day she was asked by front office staff to please go outside and summon another client. People had to wait outside the front door because the waiting room was overcrowded. When my informant went outside and returned

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213 w ith the scheduled client, someone had taken her seat. This scenario happened to her twice the same day. Waiting time can take up to two hours. Usually though, my calculations indicate that up to 15 minutes is closer to average. Yes, it' s true that some days are better than others. I wanted to learn what EP clients thought was the most important feature of a community center. Therefore, on the patient satisfaction survey, I posed the following query to 138 clients: please place only ONE CHECK by THE most important feature of a health care clinic. I included the following choice categories in this order: its clean appearance, courtesy of the staff, cost, the doctors and nurses ability, my ability to schedule a convenient appointment, brief wa i t time in the waiting room, or if you wish, you may fill in your own most important feature of a health care clinic. The results are presented in the following table. The ability of EP doctors and nurses seems to clients to be the most important feature of the center. This conforms with the data I obtained while conducting six in-home personal interviews. Certainly, it is important to treat clients with respect and understanding. This is particularly so when people are feeling ill and vulnerable. Also, quite a few clients did mention the facility' s cleanliness as being important to them.

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214 This finding also conforms to information I garnered via personal interviews. Table 19. In EP Client Opinion, The Most Important Feature of a Health Care Clinic Doctor and Nurses Ability 38% Courtesy of Staff 22% Clean Appearance 15% Schedule Convenient Appointment 9% Cost 6 % Brief Waiting Room Time 4 % Other 6% What is quite surprising to me though is that the variable "cost" is so far down the list. It is hard to explain. It does not conform to the data I gathered when I personally interviewed clients. Nor does it conform with many informal conversations I had with numerous clients over the many months. What I can do with this information is merely provide a hypothesis. In this regard I recall that these satisfaction surveys were filled out by people about to receive medical attention. Perhaps at that point, people are feeling a little nervous. The concern here may really be about the staff's medical competence. Perhaps at this point, cost really seems less significant.

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215 As an anthropologist, I believe an important variable is whether or not an institution is located on a convenient "trading route." EP is so located, on a well travelled avenue. It is served by two bus routes. Still for some, getting to the center may require up to three transfers. Others who use a designated taxi company, can take a medicaid reimbursed ride. Additionally, an EP agreement with a local senior services organization permits reliable volunteers to pick up and return many senior citizens. One informant told me a rather interesting means by which she comes to the center. She told me she used to have a car, but she sold it to her ex-husband. Now she has to borrow her "sister's bomb." She said its all rusted out but "it goes wh -ere I want it to." She could not now afford her own automobile. Another woman of about 60, always tried to have her appointment scheduled first thing in the morning. That was because her children could take her on their way to work. On the way back, s h e takes the bus. She does have to transfer once, but if the busses are "running together," she could be back home in 30-minutes. A client told me that she relies completely on public transportation to come to the center. She takes a bus by her house, and then makes two transfers. Because she is handicapped, the charge for her long ride is 45 cents. Her travel time is generally one hour each way.

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216 A middle aged woman told me she had lots of helpers to get her to the center. She said when she needed to go she would first ask her children. If they couldn't bring her, perhaps her grandchildren would. Failing that she said, "my sister or my brother will carry me." Friends and family word of mouth has been demonstrated as the means most clients hear about and attend EP. They also seem useful in terms of providing the necessary transportation. The fact that the health care center has rather convenient hours seems to be a help to many people. EP is open 8 A.M.-9 P.M. Monday through Thursday, and 8 A.M.-5 P.M. on Friday. The center is also open Saturday. Typical of client comments addressed to me was a woman whose physician sent her to EP because it was open at night. She needed to stay on the job and unfortunately, her doctor did not maintain evening hours. She said that she was grateful EP was open at night. She believed that the community desperately needed a health center which could accommodate working people. Similarly, I spoke with a client who was a medical assistant at a local nursing home. For years she had visited a local private physician. But unfortunately, the waiting time in her doctor's office was simply too long to accommodate her busy schedule. Also she said her doctor didn't "run late." The EP center does. She appreciates and makes use of the center's evening hours.

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217 The center contracts with local hospitals to obtain physicians who augment full time staff. Their duty hours are generally 5 P.M. to 9 P.M .. This proved to be an important asset in attracting some patients. Typical of this genre was a 22-year-old pregnant woman. She had to work days and again, her doctor's daytime only hours weren't convenient. She was grateful for, and made use of, the center's evening and Saturday hours. She also believed that if you get the doctors from the hospitals, "they have to be good." An impassioned staff physician believed that the center's expansive hours of operation are critical to the health and well being of this neighborhood. She thinks everyone is entitled to decent health care. She maintains that just because you are of low income, "that doesn't mean you have to stay at home and watch your child die." Systemic Cost Effectiveness The Evelyn Perry Community Health Center was started by local clergy, politicians, and community activists. It's purpose was and is, the delivery of affordable health care to local low income people. Fortunately, federal funds were available for just such an institution. In order to qualify for federal funds (under Section 330 of the Public Health service Act), the center must be structured as a nonprofit corporation whose main charge is to

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218 provide comprehensive primary care. Services will include acute care, health maintenance and prevention, obstetrics, family planning, hospital admission and follow up. The center is to have an clinical staff (including full participation by non-physician providers) as evidenced by: an appropriate number of full time boardcertified or board eligible physicians, non-physician providers and clinical support staff such as nurses and medical assistants, and leadership by a clinical director who regularly interacts with an executive director and a board of directors. The center must have a hospital admission and coverage plan ensuring continuity of care and discharge planning. Physicians at a federally funded CHC must have admission privileges and medical staff membership in one or more local hospitals. The health center must have in place, a system of organized referral arrangements to assure quality specialty medical, diagnostic, and therapeutic services to patients. Also, to assure that the center is closely linked with its environs, the center's governing board must be composed primarily of community residents, a majority of whom must be center clients. Other neighborhood health institutions send clients to EP. Among these are the county health department and local

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219 hospitals. Hospitals are only too happy to send their low income patients to EP. On this matter, it was the opinion of the Executive Director that the local hospitals do a fine job but their caring for low income patients is extremely inefficient. He used the analogy of General Motors being a fine company but they could not well manage a mom and pop corner candy store. The Evelyn Perry Community Health Center as most federally supported CHCs, is a nonprofit organization. An explanation of center efficiencies will shortly transpire. But to begin, I can now say that as is common with many CHCs, much of EP's medical equipment is donated or purchased as significant discount. Further, as is also common for this institutional environment, the rent payment is minimal. The Evelyn Perry Center, for example, pays the church landlord one dollar per year. What I believe will be shown is that EP is able to pass along these economies of scale in its client pricing policies. A CHC is required to have contractual or other arrangements with the state Medicaid agency for payment. Rates are negotiated annually. As of April 1, 1990, states are required to pay "federally qualified health centers" (FQHC's) one hundred percent of the reasonable costs of providing FQHC services and any other ambulatory services otherwise included

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220 in the state Medicaid plan. As of October 1, 1991, FQHC's also will be entitled to one hundred percent reimbursement of their reasonable costs for services provided to Medicare beneficiaries. A majority of states (including the one I worked in) pay CHCs on a fee-for-service basis. These are generally equivalent to physician fees. The centers may make up any financial deficit in their overall operating grant and by other voluntary contributions. Because EP' s costs are lower, the center is able to charge Medicaid and Medicare (the taxpayer) a lower rate than could a hospital or likely, a private practice physician. The following table illustrates many of the major EP cost centers. Among these illustrative cost centers, I call particular attention to the last, P hysician Insurance." This category represents an enormous systemic cost savings. Many physicians today complain about the exorbitant costs of medical malpractice insurance. In some medical disciplines such as obstetrics, it is not unusual for a physician to pay $150,000 a year for coverage. But at EP, and in most CHCs the institution can purchase insurance as a group buy. It can even purchase in conjunction with other institutions. In the case of EP physicians, they were placed in an enormous insurance pool. In this way, the savings can be passed along to clients.

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221 Table 20. Major Annual EP Cost Centers (June 1-May 31, 1992) Total Salaries (28 full time) $589,706 Physician Service Contracts 117,310 Accounting/Auditing 39,298 Leased Equipment 11,090 Computer Leased Equipment 24,548 Telephone 22,565 Electricity 772,958 Facility Insurance 2,464 Physician Insurance 34,680 Note: Approximate figures based upon a twelve month extrapolation of nine month totals available during my internship tenure. I think it helpful if I present the prices that EP charges for a variety of medical services. Keep in mind that a client can be seen for as little as $6.50. Remember too, that the fee for service which is actually paid by a client, is based on income. Again, there is a sliding scale of 20-40-60-80-100 percent of the fee based on ability to pay. The Executive Director told me of his medical treatment philosophy. In his opinion, it is fundamentally important to

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222 Table 21. EP's Standard Fees Per Service (June 1-May 31, 1992) Health Screen Adult $35.00 School Physicals 12.50 Glucose 2-HR pp 12.00 Sickle Cell Screen 19.50 Lead Screening 19.50 Cholesterol, HDL 18.00 Hypertension Screening Profile 18.25 Arthritis Profile 1 42.50 Urinalysis 14.50 Lupu s Profile 19.75 Rubella 29.50 HIV AIDS Screen 187.25 Flu Shot 5.00 Injection, Antibiotic 15.00 A/P Chest X-Ray" 57.38 Note: These fees are competitive in this particular community. treat conditions early and frequently rather than waiting to treat them when the problem is severe. He said that in this community, for example, there is a high incidence of morbidity and mortality resulting from

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223 related complications of diabetes mellitus. He informed me that the goal of EP was to prevent and or delay the complications frequently brought on by the disease through pharmacologic, dietary and educational measures. He also ventured a comparative cost analysis of treating a diabetic in three community institutions. He said an "average" single visit by such an afflicted patient might cost that person 140 dollars at the county health department, 150 dollars in the hospital emergency room while a similar visit to EP would cost a client $49.83. Considering financial cost and good medicine, it is better to treat people before they get sick. Opinions of various local community representatives about preventive care and treatment traditions were gathered by interviewing physicians who either are or had been practicing medicine in this community. One doctor I listened to said that in his former praetice, he had seen more than his share of people with high blood pressure 1 enlarged hearts 1 diabetes 1 and rheumatic disease. He informed me that approximately ninety nine percent of his patients were like himself 1 African American. He said that when he started his practice in 19551 he had to have a white man "buy" the office space for him because he was not permitted to do so. He told me that in his practice, he experienced very few people coming in for annual checkups. Apparently "they weren't

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224 used to it." Almost always did he care for patients when they were having a medical problem. A currently practicing African American physician told me that ninety eight percent of his patients were also African American. The range of maladies he treats include colds, cancer, diabetes, and hypertension. He doesn't have a secretary. People just show up and are treated. This doctor said that very few people come in for a preventive annual checkup. The Head Nurse at the community health center had for years, locally worked for still another private practice physician. She said that her employer didn't really make formal appointments over the phone. he saw patients as they came in. This informant said that there was no tradition of preventive annual checkups in this African American community. She thought that the main reason for this was people's lack of money. She said too, that many people were not yet aware that they could get a complete physical at EP for only $6.50. The internal medicine physician at the center had an interesting slant about community traditions and annual checkups. He said that generally, in the African American community (he is African American), there is little tradition of annual checkups. But he said that "the patients who see me do (come at least annually)."

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225 He drew a distinction between African American men and women. He said that many African American men think they are immortal "until they hit forty and develop chest pains." Women, he said, have an earlier sense of.their mortality due to childbirth. Therefore, women are more responsible about taking care of their bodies. Compared to the "macho male image of himself," women are far more likely to come in for preventive appointments. The center's family practice physician (he happens to be white) said that in this service area, there is little tradition of preventive annual checkups. He said he noted no difference in attitude or knowledge about this concern between his African American and white clients. In his opinion, this medical indifference was mostly a function of youth. He said that "young people don't think about it (their health)." I interviewed a Baptist minister who for 26 years, has led a local congregation. He believes that in this neighborhood, there is no real tradition of annual checkups. He cited three reasons for this apparent neglect. First, he said, people didn't have the money. Second, people lacked the knowledge that a preventive checkup was good for them. Third, he said that most people fear the doctor. To remedy this he suggested "just like preaching," go and isolate a small section of the neighborhood and build from there. He said from this section, you can come in and "spread the word."

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226 The mentioned sources as well as others agree that in this community, there is little tradition of preventive annual checkups. The consequences include both personal neglect and society's fiscal burden. These may be circumstances where a community health center can bring about positive change. The physicians with whom I spoke were generally rather happy about working at EP. That's good news, because the salaries available for them in this institution are below what they might earn in private practice or in a hospital. The Medical Director told me she really likes community medicine. It offers "greater satisfaction than money." Parenthetically, her published 1992 salary is $76,000 a year. A further benefit is that she does not have to pay for medical malpractice insurance. The family practice physician admitted that initially, he had apprehensions about working at EP. He didn't know how it would feel to have other people making scheduling decisions for him. Yet he said that it was a great relief not to have to worry about the administrative aspects of a practice. Here, he felt "free to practice medicine." The doctor was proud of the fact that he could take the time to develop long term relationships with clients. It was with a great deal of satisfaction that he said that "my patients come in and ask for me." This physician was beginning his third year at the center. He was at the center by choice. He had long ago, retired his medical school debt.

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227 For the third year in a row, a young physician regularly based at an ivy league hospital's health clinic, had joined the EP staff for a one month stay. The doctor works as a general practitioner. He says he comes for the milder winter weather and to help. Yet given his particular credentials, he really could work most anywhere. He says he has come to dislike the "businessside" of medicine. Nor does he want to "hassle with the insurance aspects" of a private practice. Assessing his priorities, he said he went to medical school to help people. He wants to leave the paper work to others. He truly enjoys seeing patients. In this way, EP does not disappoint. These positive employment experiences remind me of the television special "American Health Care, Going Broke in Style." In that program, host Torn Brokaw referred to a private practice physician term "the hassle factor." In this instance, it means the many private company and government insurance forms the doctor and his staff have to wrestle with just to get paid. The program showed that for many physicians, the hassle factor can take up to fifty percent of a doctor' s time. Yet at a CHC, staff is on hand who are expert at medicaid, medicare, and third party insurance filing. In practice, a private physician and hisjher staff, must negotiate a wider variety of forms and rules and regulations than does an average CHC. Due to the low income status of most

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228 CHC clients, the predominance of staff paper work must adhere to familiar government program guidelines. A listing of some typical EP salaries is helpful in demonstrating operational cost savings. As mentioned, the Medical Director is paid $76,000 dollars a year. The Executive Director annually earns $55,000 dollars. The social service employee earns $17,000. The base pay for medical assistants is $12,000. The salaries of these employees are raised approximately 4.5 percent a year. I was impressed that the Executive Director made operational efficiency a dominant value. He is a skilled manager. In this regard, he informed me that none of the employees, including himself, technically worked for EP. Instead, everyone worked for a conglomerate. The corporate name was similar to the pseudonym Payroll Aid Inc. This company technically employed 20,000 people. The Executive Director informed me that one of the advantages of working for such a large concern was the ability to provide inexpensive health insurance for health center employees. Unfortunately, several. months into my health center association, Payroll Aid Inc. closed its doors. They sought Chapter 11 protection from their creditors. According to the article in the business section of the local paper, they could no longer afford health insurance for their "employees." How consequentially ironic! It seems that the cost of health care and the cost of even large group-buy insurance, rose faster

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229 than the company' s ability to pay for it. Perhaps this is an early warning to policy planners who believe large scale health maintenance organizations are the panacea that will keep health care costs down. The bankruptcy of Payroll Aid Inc., certainly left the EP staff in a bind. The Executive Director turned to a major third party insurer. Fortunately, at the time, he had the opportunity to make a local television appearance. He spoke on the air of the benevolence of this private firm in relationship to their treatment of EP. He then negotiated a very competitive premium rate. Still, the plan called for a standard 80-20 insureremployee payment split. That was new business for EP staff. I was aware that a number of employees, particularly medical assistants, spoke to the center manager of their fear of.an inability to pay the requisite twenty percent of a major medical bill. The center manager relayed their concern to the Executive Director. The next day the Executive Director told the manager to inform the staff that if employees did not have the twenty percent at the time of a medical expense, EP would assume the balance. The center tried to first hire neighborhood people. Perhaps this represents a tiny but positive contribution to the local economy. For example, the head of office personnel lives nearby and was trained by the center. The same is true of the Director of Medical Records. The head nurse lives

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230 blocks away as does the Executive Director. Also, a staff pediatrician was first attracted to EP because she could be near her home and her new baby. Importantly, most on the job trained medical assistants are neighborhood residentsd This circumstance permits many to go home for lunch. In some cases, this meant a chance to check up on the kids. Nearing the end of my internship, I asked the Executive Director about health care costs to patients in regards to EP's potential competitors. He said that for the most part, nonprofit HMO's have never really passed along savings to their clients. In fact, he felt that there was no real difference between nonprofit and for profit HMO's as far as clients were concerned. Perhaps one minor difference he noted was that the managers of the nonprofits would likely earn less salary. The Executive Director said that EP breaks out monthly profit center reports. In this way, management can easily identify the income producing areas and the money losers. Perhaps in theory, EP could stop performing money losing services. However, the Executive Director said that "the Board of Directors would never stand for it and they shouldn't." I return to the issue of affordability and medical care availability. On the Patient Satisfaction Survey, I wanted to know how many EP clients used to see a private doctor. I phrased the question as follows:

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231 28. Check one ... Did you used to see a private doctor? A. Yes B. No If yes, for what reason? ______________ Out of the 200 questionnaires distributed, I received 138 responses. Only thirty two percent of respondents used to visit a private doctor. I was surprised and saddened by this relatively low percentage. The related question 29 is as follows: 29. If you answered Yes to question 28, why did you leaveyour doctor? -----------------------------------------Although thirty two percent of questioned EP clients used to see a private physician, sixty three percent, said they could no longer afford one. Many clients ignored the qualification "if you answered yes to question 28" and reported that they could not afford private medical care. The actual percentage of people who would say that they could not afford private medical care is probably higher than here indicated. I believe some clients did observe the "if you answered yes" admonition. From the survey responses, we learn that many people in this particular neighborhood have little experience with private preventive medicine. The numbers are probably even more tragic when the reader considers that I asked people who were already seated in the health center. What of the majority of neighborhood people who have never come through the health center's door?

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232 Additionally, we learn that cost is a large prohibiting factor in people's desiring to seek out private preventive health care. This contrasts interestingly with the findings described in Table 19. There, we noted clients thought that cost was way down the list in importance when considering the most significant qualities of a CHC. EP prices as indicated, are quite reasonable. Additionally, I repeat my belief that when a person is about to see the doctor, the quality of physician care as well as staff courtesy suddenly become most important. Next I wanted to learn that if people were not seeking out private medicine, where had they gone for care before EP. Survey question 30 was as follows: 30. Check One ... If not a private doctor, who did you visit for your previous medical needs? A. The County Health Department B. The hospital emergency room C. a hospital clinic D. The Free Clinic E. other-please explain: ________________________________ __ The survey indicated that twenty two percent of the 138 respondents had visited the county health department. I recall that the county was now capping the number of patients it could afford to handle. The local hospital emergency room was visited by twelve percent of EP clients. The emergency room alternative is very systemically costly.

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233 The hospital's clinic was visited by six percent of the center's clientele. At the clinic, long hours of waiting was the norm. Numerous EP clients told me that the hospital clinic would give them a hard time when paying through Medicaid. In fact, some clients had been refused service. Five percent of respondents had gone to The Free Clinic. This well intentioned and ongoing organization was staffed almost completely by volunteers. Among the hurdles presented at this organization were inconvenient operating hours. Additionally, personal physician-patient relationships were apparently not the norm. Fourteen percent of respondents checked the "otherplease explain" category. Typical of this kind of response was that the client had visited a county health department in another city. Forty percent of respondents did not answer this particular question. On June 14, 1994, I had the opportunity to listen to a health care address given by the present First Lady of the United States and health care planner Hillary Rodham Clinton. She was speaking to the North Carolina Chamber of Commerce and fortunately the speech was carried on C-Span. Among her keen systemic observations, she noted that presently, when a fully insured patient checks into a hospital, they are paying on average $25-dollars extra for their room. This is due to hospital "cost shifting." The term refers to the padding of

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234 bills in a variety of institutional cost centers that hospitals must perform in order to remain financially sound. The hospital is forced to absorb the cost of non-paying or medicaid paying emergency room cases. Very frequently, these cases are not real emergencies. It's just that many people have nowhere else to turn. Additionally, many middle class people today who think they can pay for a hospital stay are surprised to learn that they are under insured given present healtn care costs. Frequently, the hospital has to absorb at least part of these bills as well. The First Lady, in addressing some of North Carolina's most successful business leaders noted that not a single entrepreneur could long survive if on every transaction, they had to pay a similar surcharge. Presently most hospitals have to perform in this way. That is why many of today's patients are forced to swallow a $15.00 dollar aspirin tablet. It would seem that a community health center such as EP is well positioned to advocate cost saving preventive care. It is cheaper, and in my view, more humane to treat people before they get sick. The Evelyn Perry Community Health Center had done well 1n obtaining federal grants. For example, a federal grant has been instrumental in backing the center's free pre-natal classes. Discussions include proper mother and infant nutrition, the importance of periodic check-ups, and even crib safety and toddler-safe toys. Lamaze classes are similarly

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235 supported. As previously mentioned, these classes are meeting the needs of many of this neighborhood's clientele. Another important grant achieved by the center was for the early intervention in locating and caring for HIV positive residents. This grant was obtained during my internship. As the Executive Director wished, it was won in partnership with other institutions. In this case, the appropriate partners included a local major university, and a drug rehabilitation organization. On my last day of the internship, I once again had the opportunity to interview the Executive Director. I asked him if he thought a community health center like EP was part of the solution to America's health care crises. He said that EP "was a good government investment. We are low cost and run efficiently. The government gets its money's worth"-(when spending on EP). Ethnically Sensitive and Neighborhood Wise The medical director of the health center is a woman of Puerto Rican descent. She says of her duties that she is exposed to more of a variety of pathologies. She says that makes medicine more enjoyable and challenging. Diseases which she has treated in this environment include: Tuberculosis, skin infections, atopic dermatitis, Sickle Cell traits,

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236 Hemoglobin C Disease, Syphilis, Gonorrhea, and cocaine exposure. A majority of her days are spent in the organization's north county health center. The northern part of the county as opposed to EP' s neighborhood, apparently contains more people whose primary language is Spanish. Unfortunately, the health department in north county does not have Spanish speaking physicians. She notes that clients come to see her often after they have visited another physician. In this way, Spanish speaking people can comprehend the first physician's diagnosis and treatment recommendations. The medical director told me that Spanish speaking people have heard of her simply by word of mouth. As a recent example she told me that a single client, a woman of Brazilian ancestry, brought eight separate families to the northern health center. This physician's history in community medicine is informative. She came to this county after serving for several years at a community health center about 200 miles south of her present employment. She had worked in a county which contained 25,000 permanently residing Spanish speaking people. This number became much higher during crop picking season. Upon accepting her new position, she had learned from her southern colleagues, that the number of Spanish speaking clients visiting her former health center had dropped dramatically. Apparently, her replacement did not speak

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237 Spanish. Therefore, despite the expense, many of her former clients were seeking out private Spanish speaking physicians. The medical director was recently informed that her former employer had hired a Spanish speaking doctor. She was told that the number of Spanish speaking clients was once again, on the rise. As I was sitting in her north county office, she told me that she was frequently "a liaison" to frightened Spanish speaking residents. Just as she was telling me this her phone rang. The caller was a Spanish speaking woman who had just returned from visiting another doctor. It seems that her baby girl had developed 104 degree fever. Apparently the mother had not understood her doctor's treatment regimen. The medical director was quick to reassure her, told her what her prescription would do for her child, and instructed the woman on how and when the child should take her medicine. My informant told me that she gets calls like that a l l the time. The number of Spanish speaking health center clients is rapidly growing in north county. That's good news as I'm told there are 15,000 such people in that community. The doctor told me that it's just that they're "hidden from the census" and tend to live in hard to find areas. The medical director is, of course, also frequently at EP. She said that she often reads literature written by leading African American authors to try and keep current. But she says, that while this helps, she is disadvantaged because

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238 she doesn't mingle in her client' s daily lives. She believes that a physician not up on local mores and jargon, might not have the sensitivity to ascertain the client's "real complaint." In that way, she says, the physician could lose the client's trust. She says that this lack of linguistic and perhaps cultural familiarity, could get in the way of client medical treatment compliance. She is proud though that she introduced Sickle Cell prep as a common .feature of EP client care. She also feels good about getting staff to consider client risk factors. Some of these indices include age, ethnicity, and sex. Her predictions for the future of training culturally sensitive physicians who would work with low income people are not optimistic. She believes that American medical students have little contact with low income people. Further, she notes that over the last dozen years or so, the federal government has cut the budget for scholarships which assist minority students. The result of this fiscal belt tightening she believes will be that it will become harder to recruit and retain doctors for community health service. I had an opportunity to interview the registered nurse practitioner. Her specialty is pediatrics. She is a light skinned Jamaican women in her thirties. She was pleased to speak about the issue of ethnic similarity and sensitivity in client care.

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2 3 9 The nurse said that she recently had a Jamaican client who was overjoyed that her nurse was as well. She said too, that 1n her case, "my skin color helps to eliminate barriers with most patients." She quickly added that she has "no problem with whites." Indeed not. She is about as friend l y as can be. In her opinion, similar background breeds trust. She also feels that ethnic sensitivity helps bring clients through the health center door. However, there was one variabl e which she found that was even stronger than ethnicity. It seems that she was the mother of a seven-year-old. She frequently communicates this to young mothers to let them know that "we're all in the same boat." She knows that helps as "it puts mothers at ease." The Head Nurse who is African American does believe that African American medical practitioners have what she describes as a big diagnostic advantage when caring for "their own She thinks that African American practitioners could obtain more and faster medical information from a c lient of s:i,milar background than could their white colleagues. She used as an example, a condition called Cyanotic. The symptoms include breathing problems and ashen skin color. Fingernails of the ill person turn purple. Lips turn a darker shade. The person can go into shock. She believes that an African American physician or nurse would seize upon these symptoms faster than white care givers.

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240 The Head Nurse also offered another perspective concerning ethnic similarity. She views herself and other African American professionals as community role models. She would like to communicate to African American clients that "you can follow in my footsteps." The EP pediatrician had a different view. She said that staff ethnic similarity might have an effect on client population. But she wasn't sure. She had worked for EP for years and has never heard the phrase, "oh good, you're black." However, many of her clients upon first meeting her have exclaimed, "oh good, you're a woman." She said that teenage mothers in particular feel comfortable with that. The internal medicine specialist is also African American. He believes that the image of an African American physician makes a difference because of its inherent community statement. He says that a practitioner such as himself makes a difference in the neighborhood as people assess what power is and who controls it. He too sees himself as a role model. However, as to a medical practitioner's ability to attract and treat clients, he says that ethnicity makes no difference. I asked him if his clients would be attracted as enthusiastically if EP hired a Swedish doctor as his replacement. He said, "yes absolutely, there would be no difference." He did backtrack a bit. He said that getting a client's history is "cultural." By that he meant that a person who has

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241 little experience seeking medical attention can give rather idiosyncratic health accounts. He said, for example, a history can unfold in the following manner: Dr.-When did you first notice your chest pains? Cl.-It was after Mary had her baby. Dr.-When was that exactly? Cl. -You know, it was n ear the time that Sister Lena moved next door. Dr.-Can you tell me the exact time you started not to feel well? Cl.-Don't you know? You're the doctor! The physician said that living and working in the community probably does give you an advantage when it comes to taking a medical history. But he also noted that if a client starts coming to a physician on a regular basis, they learn to give "a good history." He equated this budding talent with a student becoming "test wise" after years of academia. The Family Practice staff physician is viewed as kindly and very talented. He happens to be white. In his opinion, the ethnicity of the medical providers makes no difference to clients. He says that people who come seeking care are not necessarily more comfortable with a doctor of similar ethnic background. He notes that many physicians, including himself, have completed their medical training in the inner city. This physician is a graduate of Northwestern University Medical

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242 School but he completed his residency on the south side of Chicago. He does believe though that it's a good thing that African Americans are on staff. He thinks that by EP' s ethnically representing the community, it conveys a comforting message. I recall though that this doctor believed that there was a more important variable than ethnic similarity concerning the issue of client comfort and familiarity. The key factor for him was the client's desire to form a relationship with a single physician. This, he said, was not possible at the county health department. But at EP, he noted that clients want the ability to ask for their doctor. In fact, this was, he said particularly true of senior citizens. They wanted to be assured that doctor X would always be there to take care of them. Thus far in this section, I have portrayed the opinions of EP medical personnel concerning the question of ethnic similarity and a greater client comfort level. It now seems appropriate to present the opinions of interviewed clients. Often with clients, I would ask a question about the importance of similar ethnicity as well as their belief in the EP doctor's diagnosis. My purpose in this was to try and learn just how much authority they were willing to grant the medical practitioner. One of the in-home interviews I conducted was with a 28-year old white woman who was blessed with five young children.

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243 This particular client said that she never disagreed with the opinion of the EP physicians. This was true in her case. It was also true concerning the care of her children. She said it didn't matter at all that her doctor and much of the staff was African American. She said matter-of-factly, "they wertt to medical school, I didn't." I interviewed a 60-year old African American woman. She believed that there was no advantage (or disadvantage) in her being treated by an African American physician. She said that the most important thing to her was that the practitioner "treat her nice ... as a person. That's all I care about." She also said that the age of the doctor didn't matter either. Nothing else mattered to this client as long as she was "treated right. A white woman in her thirties had a similar opinion. She didn't care at all about her physician's ethnic background. In her case, her EP doctor happened to be African American. She said her EP physician offered good care. She went on to say that the way she is treated at EP "is real good, on Medicaid." She said that she had been to other providers who had treated her poorly because she was on Medicaid. I had the opportunity to visit the home of a 79-year old African American gentleman who happened to be sightless. He offered that it made no difference to him whether his doctor was African American or not. He told me that "I don't have no time for prejudiced people." I. asked if he believed the care

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244 regimen suggested by his doctor. He said that "I have never studied medicine so I have no problem with that. I let them (doctors and nurses) do their jobs." I pressed and asked if he tried home remedies instead of the prescriptions or advice suggested by his EP doctor. He said that "I don't let that touch me. If he says it's an orange, it's an orange." I informed the gentleman that i t looked like his physician was going to soon leave EP. I asked him if it mattered that his new doctor would not be African American. He said that "if he (the new physician) had the knowledge when you really need him, that's all that counts." I visited the home of a very pregnant 2 2-year old'white woman. Her primary EP physician was an African American woman about 10-years her senior. The client said that she never had a disagreement with her physician's diagnosis or treatment schedule. She said her doctor was "always open with me." During her latest EP visit, the doctor informed her that she was diabetic. That is why the client scheduled a follow up appointment. Particularly because of her pregnancy,, she understands and respects the importance of her doctor's diagnosis. She concluded by saying that she hoped that everyone believed what their doctor had to say. She noted that "everyone (of the doctors) had an education. It doesn't rna tter who sees you as long as they know what they're doing." She thought that the idea of a person preferring a doctor because

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245 they were of similar ethnic background "only mattered to prejudiced people." A forty-one year old African American woman related to me that about a year earlier, something was physically wrong with her daughter. She wouldn't specify the malady but she did say she took her child first to the local hospital emergency room and then to EP. The two physicians offered two different diagnoses. Ultimately, the EP's physician was proved correct. She has been a health center client ever since. She said that at times people might feel more comfortable with a physician of similar ethnic background. She was concerned by what she called her "comfort level." In this manner, she said that she could tell the center's present internal medicine specialist (also African American) anything about her health. She was comfortable with him. She said that she would say a great deal too, to EP' s new replacement physician but she felt that since he was not African American, it would take her longer to warm up to him. That said, I cannot tell if in the final analysis, she was concerned very much with ethnicity or was simply having jitters about meeting with an unfamiliar physician. This client did offer an opinion about senior citizen physician preferences. She said that she thought that older people would feel more comfortable with a doctor closer to their age. The woman said that she felt more comfortable with a physician nearly her age. The internal medicine specialist

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246 was 44-years old. Yet she felt that there was "no difference at all" when it came to her own comfort level and a physician's ethnicity. This woman used to visit a private practice physician. But during the last year she had found that she could no longer afford his fees. She was initially sad about having to come to ''a clinic." Btit she said that the EP doctor quickly and correctly diagnosed her condition as "coppertone syndrome," which was located in her hands. At this time she felt positively about all of the EP physicians. She would certainly be seen by any of them. She said that ethnicity didn't matter and that ''they were all professionals." In the patient satisfaction survey, I addressed this issue of ethnic preferences by clients of their medical care providers. I asked clients the following question: 20. Check one: Being seen by a doctor or nurse practitioner of my ethnic background would make me ... A. a more comfortable patient B. a less comfortable patient C. it would make absolutely no difference Forty-nine African American clients answered this question. Among this group, a full eighty eight percent said that the ethnicity of their doctor or nurse practitioner would make absolutely no difference to them. Ten percent of this group said they would feel more comfortable with an African American medical provider. Two percent or really only one

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247 African American client said she would feel less comfortable with an African American practitioner. I performed the same kind of break down for white clients. Thirty-six of these clients responded. Among this client sample, eighty six percent reported that the doctor or nurse's ethnicity made absolutely no difference to them. Only fourteen percent of the white clients queried said that they would feel more comfortable with another white person as their medical provider. One of the clerics that I interviewed told me that African Americans have no tradition of annual check-ups. He also said that traditionally, they would only call a doctor in extreme cases. The hesitancy he believed was due to their lack of income. The minister believed that they would first try home remedies. An example of these would be boiling petroleum jelly in the room where the sick person lay. This procedure was thought to cure colds. Yet in my particular experience, I discovered an overwhelming confidence in the white coated medical practitioners. Treatment regimens were rarely questioned. The doctors were thought of as "educated" so that they were given great treatment license by their clients. Additionally, there was little evidence that clients preferred a practitioner of their own ethnic background. By and large, the "white coats" seemed to be the only color that

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248 mattered. In this community, it seems that most people readily accept the traditional hierarchical major medical model. Interestingly, medical practitioners spoke of linguistic considerations, diagnostic advantages, role model perceptions, and taking client histories as important cultural variables in the delivery of medical care. Most clients on the other hand, were pleased to permit the white coats broad license when it came to their own care. In their view, cultural variables were not terribly important. Medical competency seemed to be nearly the only variable that mattered. There was, however, an interesting exception. I was intrigued by a pediatrician's discussion of client response to the effect of "oh good, you're a woman." I sought more of such opinion in the patient satisfaction survey. The question as posed and the responses of 125 female clients follow. 16. Check one: I prefer being seen by a doctor who is a. the same sex as me b. the opposite sex c. the doctor's sex makes absolutely no difference The survey demonstrated that seventy two percent of the queried women said that the sex of their physician made no difference. However twenty two percent of these clients said that they would prefer a female physician. Only two-percent preferred a male doctor. The survey results imply a community need for female physicians. At this particular CHC, both pediatricians

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249 including the Medical Director are female. The head nurse and the registered nurse practitioner are as well. The family physician and the internal medicine physician are male. The following accounts are designed to give the reader a "feel" of various aspects of health center life. To this matter, I begin with my client survey on the need to change the EP telephone system. The Executive Director had asked me to conduct an informal survey. I complied by speaking with clients for four hours. The director had become concerned that clients were being kept waiting on the telephone for too long a time. Therefore, he was prepared to install an efficient but expensive "telephone tree" system. Specifically if implemented, a client would be able to "press 'one' for an appointment or 'two' for a billing question, or 'three' if they needed a prescription reordered." These represent just a few of a touch tone callers choices. I explained this new system to over 50-clients. I mention too, that at the time of this writing, this system is relatively widely used in many institutional venues. The results of my informal survey surprised me. Nearly unanimously, clients preferred to keep the present system. This was true even though the delays were growing due to the increased client population. The system was popularly rejected because clients wanted to speak to a "real person" rather than either listening to

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250 a tape or just recording a message. A client offered that he recently called EP and had to let the phone ring ten times before the receptionist picked up the call. He said he'd much rather do that than be put on hold by an electronic system. Others did not yet have a touch tone phone. Also, many just "liked it the way it is." They just resisted change. Typical of the comments I heard was the following: "one time I called and I waited over an hour but that was o k . When you have no money, you have to expect those things. Unfortunately, many responses evoked the condition of low income clients and how they had become used to low expectations. I am aware that there is another telephone number for administrative calls. These calls don't go through the switchboard. Might white collar people have different telephone response expectations? I do know that the new general system was not installed. The Executive Director told me that the center had just saved $12,000 dollars. Continuing with our theme of offering the reader the feel of the health center, I turn to a completely different experience. I have mentioned that I had real symptoms when I went for a complete physical in the role of EP client. Well, I believe a sick or worried person has altered and at times sharper appreciation of their environment. At least this was my history.

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251 When I came to the place in the waiting room where I was to talk through the little hole in the glass to inform the front office I had arrived, I was ignored for what seemed like eternity. It was probably closer to a minute. A new employee was starting work that morning. There was no pleasant chit-chat that many of us in our role as patient are used to from doctor's secretaries. I got her attention and said my name and the young woman said "o.k .. To tell the truth, as I was feeling very vulnerable I could have used some pleasant "good morning" type banter or some other help from the environs. I instead, got wholly other. People's faces this morning appeared to look terribly sad. Others appeared to be just very tired. I got to sit across the room from a woman who couldn't close her pants zipper as it was broken. Clearly visible were her underpants and crotch. This appearance was orally matched by a woman sitting next to me making frequent loud sinus clearing sounds. People looked tattered and somehow beaten up. I noticed.as I think I needed something supportive to hold on to. I wondered to what degree the spartan waiting room itself was responsible for the morning's feeling of sadness. The noise level that day was near the breaking point. Children were running around largely undisciplined. When they were restrained, it was with loud parental "shut up's. Physical environments can and do shape behavior. I was glad that plans

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252 were in the works (at this writing now completed) for radically different waiting room facilities. I turn now to an issue which galvanized the community and in ways which shall become clear, even impacted my internship. The city in which I worked had a "weak mayor" form of government. By that I mean, the mayor stood for popular election. But perhaps his main job was to appoint a city manager. The mayor's duties were little more than ceremonial. At the time, the acting city manager was an African American man. He arrived at his position after the police chief obtained his job. Heated controversy erupted throughout the city when the city manager fired the white male police chief. The grounds for dismissal included being "very insensitive to minority concerns." I am aware that one of the first things the chief did when he carne to town was to eliminate mandatory police community sensitivity training. It was also specifically alleged that he bugged the desk of his lieutenant subordinate. The subordinate, an African American, was thought to be in line for the chiefs' job when the previous city manager brought in this experienced police chief with big city credentials. I did not attend any of the predominantly white prochief meetings. The force of these will be demonstrated shortly. But I did attend germane evening meetings at predominantly African American churches. The meetings were

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253 called by community business persons, clerics, and the local chapter of the NAACP. The aim of these gatherings was to keep the chief from being reinstated. In one such meeting, African American business leaders spoke of the schism between the values and sensitivity of the former chief and the African American community. Members of the audience spoke of the "martial law" city police force. Participants thought the problem to be systemic and deeper than just the ouster of a single official. But all agreed that the former chief should pack his bags. Throughout my internship experience, I was surprised at the lack of cohesion of the African American religious community. Often, clerics had perceived as one of their roles, the competing with other ministries. In fact, it had become clear to me that if EP were to go out and interact with the religious community, it would be like visiting many separate power centers. That said, when a c ity wide issue erupted with racial overtones, the African American religious community and its political representatives quickly formed a united front. The pro-chief forces were organized too. For example, they were able largely through their horne owners associations, to obtain thousands of resident signatures to place the reinstatement of the chief on the election ballot. The local newspaper conducted research on who the signers were. It found that in predominantly African American election precincts, less than twenty percent of those who voted in the last

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254 election signed the petitions. In the predominantly wh ite election precincts, petition signers exceeded one hundred percent of voter turnout. The pro-petition forces also put into question the way the chief was to be hired. In the future, if the majority voted their way, the chief would be hired by the city manager with the advice and consent of the city council. Moreover, the council was to have veto power over the removal of top level city employees. In response, the city then sued its pro-chief citizens to keep their ballot initiative from taking place. The local newspaper polled its readers to gauge community opinion. The data informs us that the city is deeply divided on this issue. The reader can see that there could be trouble ahead. In my travels through the neighborhood surrounding EP, I visited predominantly African American luncheonettes, grocery stores, storefront and cathedralesque churches, doctors offices, car washes, and local media including radio stations and the neighborhood newspaper. In each of these places, I saw "vote no" fliers posted on the wall. That meant vote no on city council having veto power over the city manager's right to hire a police chief. It also meant vote no on a city charter amendment which would place the office of Police Chief under the direct supervision of the city council. It meant vote no on a citizen initiative ordinance which called for rehiring the former Police Chief.

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255 Table 22. "What You're Saying" 1. Do you think the Police Chief should have been fired? Black response ... yes-59%, no-28%, not sure-13% White response ... yes-4%, no-74%, not sure-22% 2. Do you feel police protection in the city has improved, gotten worse, or stayed the same under the administration of the former Police Chief? Black response ... improved-21%, worse-35%, stayed the same-35%, don't know-9% White response ... improved-43%, worse-6%, stayed the same-35%, don't know-16% 3. In general, do you think that too much, too little, or about the right amount of attention is paid to minority concerns by the police department? Black response ... too much-2%, too little-68%, right amount-17%, don't know-13% White response ... too much-24%, too little-17%, right amount-39%, don't know-20% As the reader has by now surmised, the city council was dominated by white politicians, who generally served conservative interests. The population dictates this result. In this city, it is easy to asses voter strength. It's also easy to know where each constituency is located.

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256 Like many other American cities, there is a main street or boulevard which goes through the middle of town. For our purposes, we'll call this one Center Street. North of Center is home to approximately ninety five percent of the white population. And to complete this segregated picture, we can say that roughly ninety five percent of the African American population lives south of Center. In fact, African American businesses have even formed their own Chamber of Commerce because as one of its leaders told me, the original chamber "doesn't give a damn about us black folks down here." According to a recent city map, I count 80 election districts above Center. Thirty-four exist below. It now becomes clear why so many voters in northern precincts wish to strengthen the proportionally elected city council's hand. As the city administration was suing its citizens to ensure the initiatives would not be placed on the ballot, the city council met to decide this same issue. Unfortunately, the atmosphere was just crackling with tension. I attended several of these downtown meetings. The first meeting I attended was with an anthropologist who happened to be African American. I am afraid w e were the center of some severe staring. I would have liked to have believed that people were merely frightened of two anthropologists strolling the streets in tandem. Instead, I fear that we appeared to be "the" interracial couple. I recall that we were not seated in the council chamber. I told I

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257 officials that we would be happy to wait outside the chamber until some seats opened up. Instead we were asked to go to a nearby senior citizen center and we were invited to watch the proceedings on cable television. Even at the senior center, African Americans and whites sat in segregated groups. Each side cheered or booed accordingly as the debate progressed. At the end of the telecast, my colleague and I left the proceedings shaken. I really felt as if I was in a small southern town in the mid-1950's which was being forced to deal with the issue of school desegregation. I was physically upset and I felt my body trembling all the way home. I arrived early for the next meeting. They had to let me in. It was a circus. All the local media and dozens of reporters crowded the chamber. This day, it was the citizen's turn to address an open microphone. In the early morning, many African Americans told why the chief should not be reinstated. Each was booed by the majority. On this day, over 18-thousand pro-initiative petitions were delivered to the City Council. There were also over 75 pro-chief speakers. Interestingly, all were white. Each spoke with degrees of venom. They were very angry. They were angry because they were scared. They felt powerless and wanted "their" chiefs' protection. In a way it was understandable. This city had recently proceeded with erecting several multimillen dollar municipal projects. They all proved to be

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258 terrible white elephants but local tax payers were forced to pay for this extravagance. Many of these speakers then accused the city manager of bowing to pressure originating from ci.vil rights groups. several said that "we won't knuckle under to (African American) pressure groups." In fact, it was the African American business community which began this movement and civil rights groups jumped on the band wagon. Further, the acting city manager and the head of the NAACP were not exactly the best of friends. Even if they were, of course, according to the first amendment of the United States Constitution, all citizens maintain the right to organize and petition a city or any level of government for a redress of grievances. But then, the pro-chief forces should have understood this. Getting back to the proceedings, it was damn ugly. It seems that many of the whites were organized by interconnecting home owner associations. Over one hundred such associations were represented. The lines of organization looked like a Christmas tree with the president of the overall association granted extra time to speak. Most white citizens were wearing tee shirts bearing the Chiefs' likeness. The shirt was designed so as to mimic a rock and roll band tour advertisement. In bold letters it said, "Chiefs' Tour." Under these words were the neighborhoods of the home owners associations. The neighborhood designations

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259 were apparently placed as to have the familiar look of a rock band's multi-city tour. Also, outside the hall, cars bearing pro-Chief placards were circling the block with their horns blowing. It was discouraging and it felt to me like a legitimatized Ku Klux Klan convention. I must say that many white speakers said the issue was not about race. But it sure looked and felt like it was. I attended a third municipal meeting. It was time to put the issue to a city council vote. As expected all the white council members voted to put the initiatives on the ballot. The two African American members voted no. The motion carried. Shortly thereafter, I interviewed a local African American cleric. Naturally the subject of the police chief came up. He informed me that "black people are ticked off. It's a shaft. It (the city council vote) shows a lack of respect for the black community. Whites are in control politically, and economically and they abuse their authority." The impact was felt at EP. I experienced three germane encounters. First, the day after the motion carried, the head of medical records approached me. As this was mid-way through the internship, she trusted me and she knew I would be sympathetic. She was right. She spoke of the complete disgust she had with the "downtown politicians." She said that "nothing ever changes around here." She felt that the fix was in and that it was all decided before the council meetings

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260 took place. She was an African American woman in her sixties and she knew history. She knew of what she spoke. Again, completely unsolicited, a community outreach employee confided in me. The gentleman was an African American nearing his thirtieth birthday. He said that he had attended a major community meeting the previous night. I was informed that a boycott of all city institutions was being planned. He was seething. He said that the African American community was preparing to "shut this city down." But for me, the most profound and most difficult discussion on this issue was to come that afternoon. In this regard, I was engaged in a discussion with a prominent EP health care practitioner. This African American employee said that they could not come to work tomorrow. The reason was that they felt that just now, they couldn't in good conscience medically care for white people. The provider made good on the promise. To conclude the telling of this event, the African American community simply could not let this decision stand. The city leaders were also rather frightened. You see, this happened a short time after the Rodney King decision based Los Angeles riots. Early one morning with no public notice, the city council reconvened on this matter. A supposed compromise was struck. The Chief was to be reinstated as a city employee. But he was not to be connected to the police force. Instead, he was given

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261 "major administrative duties." His contract was for a salary of over half-a-million-dollars. It was also a guaranteed contract. The money would have to be paid to this official. The contract was fashioned to last three years. But, if the ex-Chief were to leave his job before the contract's end, he would still receive full payment. He kept the job for all of three weeks. The city still owed him the money. Therefore, the city's white and African American taxpayers lost again. Of course, the ex-chief might have been heard to say "how sweet it is!" He did, however, use his newly earned free time in a constructive manner. He ran for mayor. The incumbent, who happened to be white, narrowly defeated him. As we have been considering neighborhood boundaries and which constituencies live where, I believe this an appropriate juncture to address a question I've asked most of the staff and countless clients, to wit; "where is the center of the neighborhood?" I thought this helpful information to have so that I might further assess the value of EP's location. Answers, however, were telling but not necessarily specific. A typical response to the question was this clients' comment: "this is the center of the neighborhood. My home is. You're standing in it. Everyone has their own center." The client pointed out that in this city, people meet each other in their homes or in church.

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2 6 2 I asked 20-year community residents where the center of the neighborhood was. They either said their horne was or there was no identifiable center. I followed up by asking both staff and clients if they could tell me the streets which bordered the neighborhood. At the time I asked this question, I was aware that one mile east of EP, there was a large trailer park which often served as a Winter horne to mostly white northern tourists. Yet, not a single person ever corroborated neighborhood boundaries. Either the answers were very individualistic or people simply didn't know. The answers did, however, prove ultimately informative. They reaffirmed the importance of friends and family as well as church affiliations to the future growth of the Evelyn Perry center. I did learn of one other institutional type in which information is conveyed. It's called a tree and in this community, people "go under the tree." I was told of this by the Head Nurse. She informed me that in the southern United States where it's often hot, people would convene under a tree to socialize and report upon the news of the day. In this city, this practice was, as far as I know, engaged in only by African Americans. The next day, I went under a tree. Well, not really. I observed one numerous times as I circled the block in my car. At still light 4 P.M .. On this afternoon, approximately 40-people were hanging out. out of this group I observed only four women. A few of the men were there with babies.

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263 What I saw were guys sitting on parked cars and trucks congregating in defined groups. Some groups were engaged in animated conversation. Others were just hanging with each other and quietly dealing with the heat. The "tree," (there actually was one) was clearly a demarcated area. Everyone seemed to be familiar with everyone else. What was very clear was that my admission to the conclave would be next to impossible. I decided on this one occasion, not to attempt the impossible. Though I would not have access to a tree, I knew someone who did. A new employee of the health center was charged with going out alone at night and working the trees as well as other known neighborhood hangouts. She was about thirty. She used to "wear colors." She said that means that she used to be in a gang. Among her tasks was the distribution of free condoms. Then she was to inform people about the center's new HIV facility. She did not at all worry about her personal safety. First, she said she had lived in the community all her life and had many allies. Second, she felt that she could take care of herself. Third, she said nothing more serious could happen to her than had already. I now miss her effusive laugh and her very healthy heart. The neighborhood contained at least a half dozen trees. Near the end of my internship, I learned from another EP employee that the police were closing down the tree I had

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264 observed. I was told that teenagers had been admitted into that particular tree congregation. I was told that there was now evidence that crack and heroin entered the tree environment. The police had decided to make appropriate arrests and at least move the participants to another area of town. That was the second tree closing that I knew of. The first occurred before my internship. This incident relates to one of my key. neighborhood informants. A few blocks from the health center is a restaurant owned by a neighborhood veteran I'll call Mr. Jackson. His restaurant is a local crossroads. Some people come 1n for lunch. I heartily include EP employees in this group as we made our weekly "Jackson run." Others came for dinner. Still others stay all day. The bill of fare features great chicken, ribs, "Jackson burgers," and mullet platter. Mr. Jackson permitted an EP poster on his bulletin board. He also sent his customers, and particularly seniors to the health center. He seemed genuinely to care about his community. He confided in me that his best recipes came from his customers. Over the years he's been told to add some of this or some of that in his sauces. His delicious cuisine is a credit to his skill and those of many other wonderful cooks. About a year before I began my health center work, the trouble began. It seems that teenagers looking for something to do at night began congregating in front of Mr. Jackson's

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265 popular neighborhood restaurant. Within a week, Mr. Jackson's night time business was being threatened. Would-be customers were declining to run the teenage gauntlet. Obviously, Mr. Jackson was very His livelihood was at stake. So one night he gathered his employees into the small kitchen and they all got down on their knees to pray. They asked Jesus to guide them and give them an answer. Mr Jackson remembered that in his church, some pretty serious choir practice was going on. As far as he knew, there was no rule saying that choir had to practice in the church. So he met with his pastor and the deal was struck. Choir practice was to commence that even1ng in front of Mr. Jackson's restaurant. For the next two weeks, tree members got to listen to the beautiful strains of gospel music. The tree rapidly deteriorated and soon ended. The following week the police came and asked Mr. Jackson how he ended the tree. He told them he didn't end it. Jesus did. Since that time, the local religious gospel station can be heard on the speakers during all hours of restaurant operation. I now wish to relate a vignette which underscores the power of symbols. It happened that one day I was interviewing a very pregnant 22-year old client in her home. I asked her how she came to EP. She said that she was told of the health center by her friend. At the time of the interview, she had had four occasions to visit the health center. But she said

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266 something happened on her first visit which deeply impressed her. In the client washroom, there hangs next to the mirror, a octagonal (stop sign shaped) sign which says, "Stop-Fight Infection with a 15 Second Handwash. Remember, Wash Your Hands. It's Important To You." The client was tremendously impressed by the sign. She said that any place that puts up a sign telling people to wash their hands "must be clean." Because of that sign, she not only came back to EP, but she said she was responsible for nine of her friends andjor family members scheduling health center appointments. The expected wardrobe appearance for male white collar staff was jacket and tie. The Executive Director was very fond of this look. But I felt throughout, that this appearance identified me with "the suits." In all honesty, I thought this appearance somewhat limiting. The coat and tie signifies to center staff that I'm identified with the administration. I know that in fact I was. But I was uncomfortable with the perceived dichotomy. A particular incident made me more so. Early on in the internship, an African American medical assistant in her early twenties, began to talk with me at the lunch table. She said, "Sir, please don't be mad at me if I sometimes forget to call you sir. You see sir, I'm just not used to it." I immediately told her that first names work much better. She would have none of it. Throughout the nine months, this effusive,

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267 talented, and genuinely kind woman never called me or for that matter, the Executive Director, by our first names. We were both "sirred." I really liked this woman but I never much cared for her habit. When I would listen to conversation in the waiting room, many clients thought that I was somebody important. I could tell. Some clients were watching what they were saying. They were self-conscious. This interpretation that "the man" is listening apparently was not very restricted by age. One morning early in my experience, I was listening to the conversation between a four or five year old African American child and his mother. The boy asked, "mommy is that man (pointing to me) a doctor?" I began to adjust my appearance to perform the task. When I knew I was going to the waiting room, I would not wear the jacket or tie. This tactic seemed to help. Once or twice I even came to work in my beloved blue jeans and this seemed to work better still. However, I always wore more formal attire when I visited someone's home. I just thought I should show my host maximum respect. The produced results from my in-home formal dress were mixed. Some clients thought they could really open up to me as they were encouraged that their opinions would go "right to the top." They seemed genuinely flattered to be asked. Others on the other hand, were more careful. I found that even when there were cases of EP and client scheduling

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268 miscommunication, some I visited "didn't want to get anyone in trouble." It was hard to dissuade some from parroting the answers they thought I might want to hear. This born and bred yankee boy was to encounter a custom that was broad based throughout the American south. I recall that approaching December holiday time, I was having lunch with a medical assistant and the medical records director. The medical assistant told me that on Ne w Years Day, she is going to cook a whole pot full of black eyed peas. She says that it will bring her good luck throughout the year. The medical records employee told me "don't you do that child." She, a woman of about 60, said that she once made a pot of black eyed peas on New Years Eve. She confided it turned out to be the worst damn year of her whole life. Gulp! Two weeks later, January 1st rolled around. I really was in a quandary. But yes, I cooked up some black eyed peas. The year featured some of the worst physical ailments I ever had. But I also witnessed a quantum improvement in encounters romantic. So I think we may b e on to something but this procedure calls out for a more refined and scrutinized technique. It is appropriate here to present the rest of the germane results from the patient satisfaction survey. I thought it important to learn common medical reasons which bring neighborhood clients to the health center. I directly posed the question.

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269 "32. What is the reason you came to see us today? There were 138 returned questionnaires. Table 23. Reasons for EP Client Visits Prenatal-Pediatric-Check-up-Chronic painDiabetes-Prefer EP Prescription refillPap Exam-Shots-Chest pain (male)Lab work-N /A-Other-18% 13% 14% 4 % 4% 4% 2% 1 % 1% 07% 07% 23% 15% The majority of client survey responses indicated that they were attending EP for either prenatal, infant, or pediatric medical care. Also, many adults came for what they described as periodic check-ups. I was intrigued by the large number of respondents who marked "checku p on their questionnaire. This answer is

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270 pertinent to the study. Therefore, I present the responses to question thirty-six for additional consideration. 36. Do you have a habit of annual checkups? Check One: A. Yes B. No Among 138 clients who returned surveys, forty three percent said they had a habit of annual checkups, thirty seven percent said they didn't, and twenty percent either did not answer or are classified as "other." Notice that a full forty three percent answered affirmatively. You may recall that this result is in sharp contrast to the opinions offered by private doctors, clerics, and virtually the entire EP staff. It's hard to account for this unexpected result. Perhaps some clients answered as they believed we wanted to hear. I also noticed that my earlier inquiries pertained to the history of preventive annual checkups only among the neighborhood's African American community. So the -next logical step was to break down the data to discern the difference if any, between the health care habits of the health center's African American and white clients. There is another surprise ahead. A full fifty percent of African American clients said they had a tradition of annual checkups. Nearly a third or thirty one percent said they had no such tradition. The "other" category accounted for nineteen percent. Among white clients, a smaller number of only thirty six percent indicated that they had the helpful annual habit. The

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271 negative answer among these clients, totalled a high forty nine percent. According to this survey, low income African American's have a greater tradition of annual preventive checkups than low income white clients. Question thirty seven is related. ''37. Please explain why you either DO or DO NOT have a habit of annual checkups." I wanted to learn in the client's own words why they did not have the annual checkup habit. I found that twenty seven percent felt there was ''no need" to be examined annually. A high number of twenty four percent said that they could not afford it. Only four percent said they just didn't have the time. Unfortunately, a full forty five percent are placed in the "other" category. Among the many reasons for this was that it was near the end of the survey and many clients were called inside for medical treatment before they finished the questionnaire. Perhaps among the twenty four percent who said that they could not afford annual checkups, EP would be their affordable answer. The twenty seven percent who felt there was "no need" for annual checkups are perhaps reachable. They did after all, come through the door. It seems that the community offers fertile ground for habitual intervention and additional outreach.

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272 I thought it important for the health center to learn what additional social services would be appreciated by its client community. The next survey question was devoted to that inquiry. "38. Our 'family' at the Evelyn Perry Health Care Center is thinking of expanding our Social Service functions to better serve your needs and the needs of your family. Please check any TWO ideas which you or your loved ones might use." A. Establish a day care center for children B. Establish a senior center which would include a recreation program, a hot lunch program, and daily companionship c. Expand our referral/benefit negotiator staff D. Literacy training E. Lamaze classes* F. Neighborhood health fairs G. Neighborhood holiday parties H. Parenting classes I. "How to" study classes for high school students J. Talks on how to apply for a job K. Please feel free to add an idea or two of your own ... Clients offered 161 responses. The results follow.

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273 Table 24. Client Suggestions for EP Social Service Expansion Day care for childrenEstablish parenting classes-Expand referral/benefit negotiator staffEstablish a senior center-Lamaze classes*-Literacy training-Neighborhood health fairs-Job talks-"How to" study high schoolNeighborhood holiday parties-29% 18% 10% 9 % 8 % 7 % 7 % 6 % 5 % 1 / 2 % *EP based lamaze classes are presently available The results indicate that mothers have a need to drop off their children so that they might search for a job or sanity. Also, mothers would like to learn how to become better parents. The responses show too, that people want the center to expand the referral/benefit social service negotiator staff. Again at the time of the internship, a social service staff person was community savvy enough to refer clients to everything from agencies which offered free children' s

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274 clothing to inexpensive dental care. It seems that EP's clients hoped the center would expand its local networking capability. Also, I notice that there is some call for the creation of a senior center. This opinion suggests that adult children might wish to drop off their parents in a known wholesome environment. The 39th and final survey question allowed for open ended response. Sixty-three clients provided suggestions. 39. What can we do to improve services to you? I assigned general categories for the responses. I recall that at first, the Executive Director was somewhat dubious as to the merit of the patient satisfaction survey. Apparently a year earlier, another survey was undertaken and he said that he had learned almost nothing. It is with some pride that I recall the words of the Executive Director upon hearing the patient satisfaction survey results. At the time he exclaimed, "this stuff really works! You're (applied anthropologists) powerful people." Some of the assessment I was able to make was merely by way of listening to informal conversations. In this manner, I learned that seniors in particular, had a need for low cost dental care. I was aware that a major university had a local part-time clinic staffed by senior dental students. I also interviewed a cleric who twice a year sponsored a roving

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275 "dental ministry." Specifically, he would hire a van, load it with dental equipment and a dentist, and on behalf of his church, go to announced public places to serve people in need. He told me that each year, the ministry services over one-thousand dental patients. Still, these efforts were not enough. Therefore, in response to this need, EP's Executive Director began to try to pursue the employment of a practitioner and to locate some equipment. He had become encouraged to do so as he spoke to Table 25. Client Suggestions for the Improvement of EP Services keep up the good work-expand the waiting room-shorten waiting room time-improve client appointmentdoctor availability coordination-improve staff courtesy-easier prescription service-hire more doctors and 30% 21% 19% 13% 6 % 5 % 3 % provide medical literature in the waiting room-2% provide transportation*-2 % *Even though there is a taxi sign in the waiting room, it is possible that some clients don't understand that are covered by state medicaid. Additionally, a local sen1or services volunteer group helps out by providing upon request, free transportation for older clients.

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276 a CHC director in another part of the state and heard that a dental facilit y worked well in their environment. Near the tim e my internship was coming to a close, the Executive Director had gotten a promised free dental chair and some equipment. As the center was to be expanding, the likelihood was that the needed space for such a facility would become available. I have spoken of the data I was able to obtain and the methodologies used to obtain them. But EP also had proprietary boundaries I dared not cross. For example, I was not permitted t o obtain information by examining client files. These were deemed private areas to which I could not have access. In fact, this information was not even available to the Executive Director. Only the doctors, nurses, or medical assistants could examine client medical records. Similar ethical considerations were apparent in other facets of the EP organization. This was directly brought to my attention in the early days of the new HIV health center. During the first week of its operation, I was a client intake person. My job was to greet new clients, make them aware of the services provided, and to try to make them comfortable. My assignment also included appointment scheduling. After the first week, I was told by the Executive Director that I was no longer welcome at the new facility. It seemed that for reasons of client confidentiality, it was

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277 decided that the medical personnel would appointments. In fact, during hours of Executive Director too, was barred from facility. thernsel ves make operation, the the auxiliary I am in absolute agreement with both ethics based decisions. If I were a regular EP client, it would be good to learn that EP went to great lengths to guard my medical history. The prohibitions seemed to increase my respect for the organization. I was fortunate to have obtained some meaningful data from the patient satisfaction survey. I was encouraged by helpful feedback on questions concerning preventive medical checkups and reasons for corning to EP. My mission, after all, was to glean from the community people's perception of this community's health dynamic. Yet in my capacity of EP intern, i t was not easy to obtain data. from non clients. Most of m y formal work was intra-center directed. I did, however, have many informative informal conversations with people who did not attend the health center. Many of these local residents proved to be invaluable community informants. Some of their personalities and input have been described. still, there is a research hole. I would suggest that future applied anthropologists who find themselves in similar circumstances make an attempt to formally elicit answers from non client s

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278 In the neighborhood where EP is located, there is a Free Clinic, hospital clinics, the county health department and emergency rooms. These are the health care options available to local low income people. It is estimated by county health officials and the EP Executive Director, that with all of these functioning institutions, only about one-third of potential low income clients are being adequately medically served. Therefore, to really be "ethnically sensitive and neighborhood wise," it behooves future researchers to formally elicit responses from non-systemic clients. I also have another helpful story to tell for future researchers. This one happens to be on me. It was my responsibility and I know now to be more careful. One of the questions on the patient satisfaction survey was on client ethnicity. Specifically, it appeared as follows: 19. Check one: My ethnicity is ... A. African American C. Caucasian B. Asian American D. Hispanic E. Native American F. Other Now I will say that after I had designed the research tool and before going public, I was careful to have two other graduate school colleagues offer constructive feedback. They did make helpful suggestions. The Executive Director who himself has a Ph.D. in Public Administration, and the Medical Director were both enthusiastic. I also pretested. However, I was not prepared for the result.

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279 Quite a few people checked "E. Native American." Well, I was baffled. I had spent many days in the waiting room and I thought I had a pretty good fix on the health center's client population. I had seen absolutely no obvious Native Americans. Then the bright bulb lit upon the dull grey It seems I might have spent just a little too much time enjoying the company of academicians. You see, there were a whole lot of folks who thought themselves to be "Native Americans" as in "damn right, I was born and bred here." Ouch. Apparently many people are simply not up on the rarified usage of the term "native American." Therefore, in my survey analysis, I discarded all responses where I really couldn't tell ethnic identity. It was painful surgery but I deemed it absolutely necessary if I was to play fair and by the rules. But at least I made some use of this screw up. Near the end of my findings to the Board of internship, Directors. I had to report my For this meeting, I included all "Native American" responses at face value. I .then recommended to the Board that after nine months of in depth research, what EP needed was a Seminole medicine man so that the center could really relate to its clients. A hush came over the room. I do believe people were in shock. Then, of course, I told them of my screw up and they just roared. The proper information was then submitted.

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280 But let this be a lesson to those earnest souls who follow. You have to be careful to weed out academic jargon. If you can, try and design an instrument with the help of people with a similar background as your future respondents. Nearing the end of this chapter, I recall two brief but powerful EP waiting room occurrences. The first happened during an early evening pediatric appointment time. There, I witnessed a 3 -year-old African American child playing with and talking to her box of colored pencils. Using the box as a telephone receiver she said, "hello police, someone is dead on the floor." The second profound waiting room memory is of a father and 5-year-old daughter playing the hand slapping game. You know the one where the father puts out his hands and the child has to slap them before he pulls his hands away. If the slapper succeeds, then she becomes the "slapee." Well, adult and child were giggling and playing and you could just see the love of the father for his child. The child too, was giggling and she felt very safe before her medical examination. That' s what it1s all about. Beginning this chapter, I offered my perceptions of what I feared the "mean streets" of many urban areas had become. I close here with a useful metaphor. Early on in my internship, on one of my walks, I recall that my path was blocked by three bicycling male teenagers. One of them yelled, "hey." Another asked if I knew that I was standing in front

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281 of Al Capone's old house. Indeed, this neighborhood mansion had been the gangster's Winter retreat. I told the teen that yes, I did know that. The third asked "if I was from around here." I said that I worked at the EP center. All three simultaneously brightened and the first said "that's cool." They all smiled and sped off to their next adventure. It was a nice moment. I felt at horne.

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282 CHAPTER 6 DISCUSSION The essence of this chapter is a comparison of my findings at the Evelyn Perry Community Health Center with the definition of quality health care as first stated at the beginning of this text. This relationship will then be augmented by discussion of germane readings referred to in the Literature Review chapter, as these too will be reviewed in the light of my actual field experience. I seek to learn from the comparisons whether the Evelyn Perry Community Health Center offers quality health care to its community. After a conclusion is reached, I shall then try to answer this dissertation's original research question. That question again is, "do nonprofit community health care centers offer quality health care to low income Americans?" Definition Comparison For the reader's convenience, I will repeat each paragraph of the definition of "quality health care." This procedure should make comparison and analysis easier to interpret.

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283 Quality health care for a lovl income person features an accessible neighborhood facility where a familiar health provider-patient relationship can be established so that preventive life care habits are encouraged. The first part of the definition I wish to address is whether or not the Evelyn Perry Community Health Center is accessible to many community residents. What I have found is that the center is located on a major thoroughfare and is quite accessible by public transportation. Further, convenient hour. s of operation have been demonstrated. In this regard, the reader may recall that a few clients said that they have been coming to the health center because EP evening hours permitted their care. I also believe that under the rubric of "accessible,".is the physical appearance of the facility. In my study, I carefully observed the appearance of the surrounding neighborhoods. Further, I dispassionately critiqued the "message" of EP's architecture. Within this critique, I kept in mind that as some informants have told me, some people are afraid of the doctor. Therefore, I seriously asked myself if EP appeared threatening. If it did not, I pondered whether it seemed familiar or even inviting. This particular community health care center did not appear threatening. Specifically, answering some client concern, it did not from the street, appear overly medical.

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284 Instead, it looked like a neighborhood home. It was physically attached to a lovely white church whose main feature as viewed from the avenue, was a dignified looking steeple and cross. The nonprofit community health center is finam::ially accessible. This is a fundamental principle of existence. In the case of EP, it has been demonstrated that standard fees are very price competitive within the venue of the other local medical institutions. Further, clients may pay on a sliding scale based on their reported income. The scale formula is 20-40-60-80-100 percent of standard fees. A client will also be seen and even given a complete physical for $6.50. Also, while EP is not a free clinic, it has been my experience that usually, people with no money are seen. It is rare that people are turned away. Finally, I have discussed how clients needing specialized medical attention will generally receive same either gratis or low cost if the referral comes from the EP social service department. There is still another way to measure EP's accessibility to its client base. That is, to measure annual client volume. While at the internship, I noted that client visit volume was increasing fifteen percent a year. As the Chairman of the Board of Directors said, "they're bursting the sides of the place." During the time of my internship, the center was responding to 15,000 annual client visits. This volume and increase, helped make a persuasive case for a major federal construction grant.

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285 I shall now examine whether or not within the environs of EP, a familiar health provider-patient relationship could be commonly established. By way of comparison, I remind the reader that evidence from the county health department (informant and my own) has shown that patient-same doctor relationship was extremely Informants and EP physicians have said that in that other facility, people can be treated like cattle. They are generally called in numerical order. So there is not much chance for a close patient-physician relationship. At the EP center, there appears to be a good chance that a client-provider relationship can develop. We have observed that the doctors are pleased when clients ask for them by name. Usually, client requests are honored. Again, though, this generally occurs because care is divided by medical subdiscipline. But because of this practice, patients are frequently turned into repeat clients. In this regard, I had asked clients who had left their private practice physician about the differences of the two experiences. To my surprise, the differences were often minimized. Finally, it mus t be reported that on the issue of provider-client relationships, that clients don' t always see their same physician. At times, schedules simply get too backed up. Physicians get ill or take vacations. There are no guarantees. None are implied. Yet fortunately, same physician

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286 care usually happens. In this way, the EP system may mimic private practice procedure. The circumstance of an ongoing client-provider relationship may at least permit the encouragement of preventive life care habits. I recall that some of the waiting room signs, for example, spoke of issues such as: no alcohol during pregnancy, crib safety, and child toy safety alerts. I recall too, that a relatively high number of African American clients (fifty percent) said they participated in annual checkups. Whether some of the residents answered affirmatively because they thought that's what EP wanted to hear or not, the survey revealed that a significant number of EP clients thought them important. The internal medicine specialist had said that a majority of his clients initially did not have a preventive life care orientation. He said that after they had been with him awhile though, they definitely did. He encouraged at home low fat diets, exercise, and the reading of supermarket product nutri tiona! ingredients. He also lectured clients on the e.vils of excessive alcohol intake and the use of tobacco products. He did believe that he changed life care habits. Whether it was a pediatrician offering pre-natal advice, the family practice doctor discussing the importance of nutritionally well balanced meals, or a physician informing teenagers about the ways in which sexually transmitted diseases may be prevented, I do believe that in this health

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287 center venue, healthy life care habits are encouraged. we have observed that the medical staff does have great client credibility. Their advice does have impact. The second paragraph of the definition of quality health care is here repeated. Quality health care means that health care providers must be ethnically sensitive and neighborhood wise so that dynamic community conditions such as, for example, lead based paint ingestion, domestic violence, and the rise of HIV, may be considered in effecting health care outcomes. The Medical Director, a woman of Puerto Rican descent, deliberately reads literature written by African American authors. She believes it her shortcoming that she doesn't know the local street slang. But she recognizes the importance of same and tries to keep up. We have seen that the Medical Director believed that ethnic sensitivity builds client conformance to recommended medical regimen. Recall that the Head Nurse thought that African American health care providers as opposed to, for example, their white colleagues, would have a diagnostic advantage in treating other African Americans. This may be true. But I found nothing in her perceptive comments which would lead me to believe that ethnic group specific conditions could not be readily learned by all qualified personnel. A practitioner could be advised

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288 to watch for specific warning signs. This is true, for example, considering the possibl e onset of sickle cell anemia. It can be true for other ethnic specific diseases too. Clients would ask for the "diabetes doctor." They had heard of his reputation. Unfortunately, diabetes is fairly prevalent in the African American community. This specialist provided ways a client might reduce their risk of becoming diabetic. He was also rather adept at spotting early warning signs. After a client was so diagnosed, he was a particularly caring and resourceful ally. He also sure had credibility. This same physician was specifically asked for by many clients who struggled with obesity. There was a small percentage of clients who did need the help of several individuals to maneuver them up onto the examination table. Again, this medical problem does seem to be afflicting African Americans in higher proportion than other ethnic groups. I note that if one were to survey the local grocery and food establishments in this particular neighborhood, they would find foods containing very high fat content, some very fatty looking cuts of meat, foods high in nitrites, and fast food restaurants galore. There is also high starch intake. It' s just cheaper. A physician who is aware of these circumstances as well as traditional ethnic diet fare can influence the way people eat. These highly thought of health providers can begin to suggest this behavioral change during

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289 private medical examinations. At the EP center, this was the case. One of the difficult problems facing this neighborhood's residents is that they cannot afford the private commercial medical system. For some, medical costs have simply outstripped their ability to pay. Others are either recently unemployed or work for employers who have stopped giving employees health insurance. The staff knows this. The medical practitioners have acknowledged that some first time clients are angry or embarrassed that they are forced to seek care at a "clinic." For example, a pediatrician told me that she had just experienced a client who told me that "I don't have to bring my child in here. I can leave and see my other doctor any time I want." The nurses and doctors patiently hear the attitude of the person and then do their best to emulate the client's former positive medical experience. Each of the doctors try to become the person's family doctor. The success rate is very high. Health center physicians have told me that occasionally, clients say they come to EP but when they can afford it, they will go back to their "regular doctor." However, as the physicians and nurses do try to develop personal relationships with their new appointments, most make EP their permanent medical horne.

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290 We have seen that the community has a preponderance of single mothers. The center has designed its care appropriately. For example, the Medical Director is a pediatrician. There is also a second staff pediatrician. Additionally, a pediatric nurse practitioner is employed four days a week. From the lovely baby pictures on the walls to the special evening classes, the center had early on understood this community' s special needs and has enthusiastically responded. Approximately twenty percent of surveyed female clients said they preferred a female physician. As described, EP easily accommodates this choice. We have observed that when center practitioners become aware of this preference, they use it to build client confidence. Such client comments as "oh good, you're a woman,11 are illustrative. I thought it important that the Family Practice physician said that he could actually schedule more tests for his low income clients than he would likely recommend if he had a private practice primarily geared to middle class patients. At EP he had the ability with the aid of the social service employee, to schedule free or low cost tests through supportive neighborhood medical providers. But as a private practice physician, he said that he would usually find it difficult to ascertain what his patients could afford as per extensive and expensive additional testing. He said,

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291 therefore, that he would have a tendency to hold back on recommending additional procedures. The center was improving in their recruitment of local candidates for HIV testing and care. Again, many client s arrived from outside EP's normal service area. The health center responded by hiring an outreach worker with strong on the street credibility. A t night, in places where people "lived," she handed out condoms and spoke of protection and testing. The grant specified assistance to African American males. Despite a rocky start, the center was eventually able to fully live up to the grant requirements. The third paragraph of the definition of "quality health care,'' emphasizes issues of actual service delivery. Health care providers must be cognizant of community service delivery issues such as transportation and convenient operational hours, as well as physician time spent with patients. Timely and suggestive patient feedback must be encouraged so that dynamic community health care and particularistic patient care issues may be included in the provider' s never ending effort at service delivery improvement. Transportation convenience is an important service delivery variable. In this regard, I was somewhat frustrated as I attempted to determine if the center was centrally

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292 located. Not a single resident could define either neighborhood boundaries or its center. Nevertheless, it does seem that EP is conveniently located. It is on a very well travelled avenue which is serviced by two primary city bus routes. If the municipal bus and private transportation are unavailable to clients, the center has made a special arrangement with a local taxi company to pick up and deliver people who are medicaid covered. Also, as the center has c lose ties to a local senior citizen volunteer group, clients who are over 65 year s old, can benefit from free rides to and from EP. The center is open from 8 A.M until 9 P.M Monday through Thursday. on Friday, the hours are 8 A .M. until 5 P M .. EP is open Saturday mornings. At other times, clients can call for medical attention on a 24-hour answering service. The Executive Director and at least one staff physician are always on call. If necessary, during an off hours emergency, a staff physician can even have a client hospitalized. Regarding the criteria of physician time spent with center clients, I have recorded a substantial amount of evidence which suggests that, if anything, appointments here are at least as comprehensive as in private practice medicine. This was the opinion of every doctor. But it was also the opinion of the nurses and observant medical assistants. Ult imately though, i t was the clients themselves who

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293 volunteered that they greatly appreciated the extra time and care their EP physician took with them. There was never a single person in any interview circumstance who told me that they felt rushed during their examination. We have noted that the EP doctors are paid an annuallj negotiated salary. Their compensation is not based on fee for service. Also, the trained EP staff ensures that the doctors never have to deal with the "hassle factor." Therefore, if a client needs more time with a practitioner, they generally get it. More than this, it was the practitioner work ethic which made the seemingly extra care possible. Each in their own way volunteered to me that clients deserve their utmost respect. In most organizations there are bound to be less caring performers. That would not be true in this case. Obviously, client feedback is encouraged. I did not observe much contact between clients and the Executive Director. The center manager did however, frequently speak with people in the waiting room. But I believe I communicated that the administration did understand and support the patient satisfaction survey. As the person who conducted the comprehensive study, I was asked by federal officials to discuss the center's relationship with its community. The Executive Director informed me that my testimony was supportive of EP's efforts to obtain a $600,000 construction grant. Ironically, this

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294 grant was to have a direct improvement impact in the various broad categories that clients had suggested. Client feedback from table 25 indicated that thirty percent of the respondents told the center to "keep up the good work." But a discernible number of people suggested that the waiting room be expanded, the waiting time in the waiting room be decreased, and that improvement could be made in the client appointment-doctor availability coordination. Happily, these concerns could be remedied by the ultimate completion of the plans for a reconstructed facility. One other client survey benefit occurred. Some had asked for the inclusion of a dental facility. As I left the internship, plans were underway to include dentistry as part of the low cost EP community service. I return to my definition of "quality health care" so that the reader can continue to compare definitional ideals with this practitioner's on site experience. The care giver must be perceived by the community as a permanent fixture offering continuous service upon which people may rely. In this regard, the provider must possess a lasting source of funding support. Its means of financial maintenance must be known by the community it serves. Further, in view of the escalating costs of medical care in the United States, the cost effectiveness to the patient

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295 and to the entire system of medical delivery must prove significant. During my internship, The Evelyn Perry community Health Center turned eight years old. A rapidly expanding constituency of community residents is aware of its presence and they have every reason to believe its not about to fold its tent. Further, after a person comes to an institution of any sort more than a couple of times, the relationship takes on a feeling of permanence. That is exactly what the EP staff has in mind. Further, the fact that so many clients have come to the center by way of friend and family recommendation, bolsters institutional community standing. As to the question of its funding support, the people well understand a medical institution which takes Medicaid clients and how it is reimbursed. The same would be true for Medicare beneficiaries. These clients may not know the technicalities, but they know it's a program administered by "the government." I think many people 1n the community know that the center was built by a government grant. Enough neighborhood people have told me this in casual conversation, that it has become my opinion. I would think too, that clients enrolled in EP's various classes would also make this government connection. Perhaps the new construction would further build community confidence in a belief that the center passes muster with Washington funders.

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296 All EP financial records are open for public inspection. I must say however, that while I was at work no single individual or group ever asked for these records. I cannot therefore, be certain, that people know of the major source of center funding. They apparently don't know the specifics. During my nine month experience, the only people asking for financial records (in addition to the monthly Board of Director meetings) were myself and federal officials. I believe it has been demonstrated that as people seek medical attention at EP, they are themselves paying comparatively little in medical fees. The center's competitive prices are often the difference between care or not. They are also saving the overall system money. It seems that clients who come to the center and get into the preventive care habit, are less likely to end up in a hospital emergency room. This saves money for the taxpayer. It also aids in preventing private major medical insurance premiums from going even higher faster. Again, hospitals must resort to over charging and cost shifting to make up for nonpaying patients. Therefore,.this community health center is an economically efficient government buy. It is popular to talk about prudent government investment. But I don't know how one can place a value on a person staying well as opposed to becoming sick. I suppose one could make the case that if an individual has the chance to enjoy unincumbered health, they, rather than being a tax

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297 burden, could become a tax payer. I do, however believe, that even the most hard hearted number cruncher intuitively know s that value here is much more than this. The reader is now guided to the fifth paragraph of our "quality health care definition." The institution engaged in dispensing quality health care shall be advantaged if it has an understanding of its financial environment. This means when necessary, the organization must have a working relationship with federal, state and local government. Yet, even these relationships, though vital, may not be enough to ensure needed growth. In this regard, a knowledge of and a relationship with germane nonprofit organizations whose job it is to dispense monetary largesse can prove important. In addition, an understanding of which other care givers in their local community have the ability and desire to provide financial, or organizational assistance, is necessary if the health care provider is to serve more community residents. And as for those constituents, they too, even in predominantly low income communities, can be a source of financial support. The provider can seek out well endowed local community

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298 benefactors. Further, public fund raising events can not only raise some money and provide health screening, but can offer the sponsoring institution public visibility and in many cases succor a community's emotional attachment. The center very much understands its financial environment. The relationship of EP to the federal government has been documented. The Evelyn Perry Center has operated within the parameters of the major federal operating grant. This center faces inspection and grant review every three years. As the relationship has been discussed, I just note here that at a time of tight social service budgets, federal largesse to the center has been increasing. Also, as demonstrated in Table 16, city contributions are up nearly three hundred percent while county endowment is off approximately fifteen percent from the previous year's fiscal budget. While at the center, I was aware that two local organizations donated funds. The first was a well known nonprofit charitable group. Their purpose was to generally "advance the condition of African American health." The second, was a local chapter of a world renowned business oriented civic minded organization. Each gift was for about five thousand dollars. Connections with large national granting organizations were being pursued.

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299 The Executive Director was expert at understanding the potential of and establishing symbiotic relationships with, would-be organizational allies. Recall that both a local drug prevention agency and a major university, co-wrote the application for a federally funded HIV-treatment center. Additionally, a local hospital provides evening hour contract physicians. Medical equipment had been donated from this source to EP as well. If one were to consider the growing health center umbrella organization of which EP was the original member, the benefits of symbiotic allies are elucidated. As such, the Executive Director realized that people in the northern end of the county were medically under served. Therefore, he negotiated with an internationally known charitable organization for the purpose of having them donate the necessary building space. They are given community credit and their signs abound on the adjoining structure. Additionally, the director was successful in negotiating a gift of several hundred thousand dollars from a north county hospital foundation. This money was used to build a new health center. The benefit for the hospital is that the health center would service their irregularly paying patients. Personal financial contributions to EP have been lagging. The Executive Director displayed great public speaking skill in his continuing efforts to raise EP's community visibility. I have seen him truly excite crowds at events as varied as

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300 large formal church meetings and senior citizen center auditoriums. These talks are extremely helpful. Yet, in terms of obtaining actual cash in hand, sadly, the results have not been terribly fruitful. There were supportive but meager dollars and coin change offered by generous citizens at a city park music fair. I recall a Saturday day-long and evening event in which numerous organizations sponsored tables. Informational fliers were there for the taking and the milk bottle money jug was ready and waiting. But I also remember that on the main concert brochure, EP's name was not listed as a sponsor. Nor was the center mentioned from the stage. Perhaps more of an could have been made. During the period of my assignment, EP sponsored no public fund raising event. Shortly after my internship, I was told that one of the members of the Board of Directors (an affluent local professional) opened his horne to a fund raising jazz concert. A splendid time was had by all. I wish I had known about it. The event raised over one thousand dollars. By way of introducing the next comparative segment, I offer the reader the sixth definitional paragraph. Quality health care means that the provider has the knowledge to efficiently intervene in the community to change and improve people's health care and life style habits. It means too, that representatives of the health care

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301 institution have the knowledge and skill to offer clients social service assistance. In this manner, the health care organization can act as a patient advocate in, for example, the facilitation of government benefits, the acquisition on the client's behalf of necessary medical equipment, and the knowledge of whom to call to keep a client' s electricity on or to connect their children with free clothing. Further, if a patient is diagnosed with a medical malady, they with the aid of the provider, must be able to network to more condition specific medical attention. It has been demonstrated, that the EP medical providers are very much aware of community disease conditions. The f ull time non-volunteer staff confronts these daily. I recall, for example, that the Medical Director said that she preferred community medicine because she could confront different types of disease characteristics. She said that in the community in which I interned, children playing o n the streets can and do contract Tuberculosis. This reoccurrence is alarming and she said it seems to occur in economically disadvantaged urban neighborhoods. The center is particularly equipped to foster healthy prenatal and well baby care. The prevention and or the treatment of diabetes, a disease all too prominent in this

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302 community, is also given rather special attention. so is the dramatic rise in HIV positive cases. To a limited extent (based on grant specifications), the center was able to begin to affect more cautious sexual behavior. Signs and posters do appear in many neighborhood establishments. The most prominent is a lively red, yellow, green and black postei with a headline which says, "A Healthy Start, A New Beginning For Prenatal and Pediatric Care call The Evelyn Perry Community Health Center." The colorful diagrams feature pregnant women, and women holding the hands of little ones. Certainly, advertisements can effectively change life style habits. Certainly, the EP social service employee and the outreach persons have the knowledge and the ability to render many kinds of assistance. Numerous examples of this care have been portrayed. So, very often, they work with the doctors to affect outcomes. For example, the doctor may inform the social service person that a client needs a particular type of home equipment which could provide for a more functional existence. Time and again, I have witnessed this low cost or even free transaction. The social service employee can and does, also ask a physician for client assistance. The doctors have written notes to prevent electricity shutoffs and, or utility bill rate increases citing medical necessity. The social service person also acts on the client's behalf to help them rapidly acquire government entitlements.

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303 This is a major part of the job. That said, I have noted that the employee spends a portion of her day helping out in the front office. I have witnessed half days when she had no clients at all. Her office is located at the very end of the hall. Some clients indicated to me that they were unaware of the center's social service capacity. The social service employee as well as the MDs, are excellent at getting clients condition-specific specialized care. It is often free. When it's not, it is almost always discounted or at least price competitive. Appointments are engaged in a timely manner. Local hospitals and a few practitioners in each medical specialty, do regularly accept low income EP clients. I believe that practitioners would be more willing to accept a low income client referred by the health center than that same client who might themselves call and ask for similar admission. The final comparative analysis between my definitional construct and my internship experience, begins here. Quality health care proceeds from an understanding that all human beings are entitled to receive timely and ongoing medical attention in a familiar patient-provider relationship. It means too, that it is better to treat people before they get sick. It also means that health care providers must be cognizant of the fact that what good health

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304 care is varies from neighborhood to neighborhood. It seems to me that the idea that all human beings are entitled to attentive and ongoing health care is the fundamental purpose of a CHC's existence. This is certainly the case at Evelyn Perry. It is the theme which is reiterated in staff interviews. Perhaps this was best punctuated by the staff pediatrician who said, "there's just no reason a mother has to stay a t home and watch her baby die." As is true of most American medical practice, EP accepts clients without regard to ethnicity, sex, or age. I say this with the knowledge that this dictum is what you would hear from virtually every practicing physician. In fact, however, when I interviewed practicing neighborhood physicians who happened to be African American, they told me that their patients ranged from ninety to one hundred percent African American. I have documented that this particular southeastern city has a history of racial segregation. As such, African American patients sought out African American doctors. In private practice here in the 1990's, this de facto tradition continues. However, at EP, people of many cultures and backgrounds really are cared for. This, in my view, represents positive change. While most medical practitioners anywhere, will treat patients without regard to ethnicity, sex, or age, I am less certain that this open policy applies as well to all types of

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305 medical illness. I believe my concern is warranted as Jeffrey A. Kelly et al. ( 1987) have documented severe prejudicial attitudes on the part of medical students against treating or even interacting with AIDS patients. To a slightly lesser extent, these same medical students harbored generally negative attitudes concerning homosexual patients. Further, Gilbert L. Solomon M.D., reports that "many primary-care physicians now refuse to treat patients with HIV, sending them instead to AIDS or infectious disease specialists" ( 1993:22). He notes that many primary care physicians don't even think to ask patients about AIDS related symptoms or going to the next step of conducting disease appropriate testing. In contrast, the community health center where I worked has actively sought to care for HIV positive afflicted clients. Unlike most physicians, of course, EP accepts clients without regard to their ability to pay. Given the present reality that contemporary medical care is very expensive, this institutional preference and requirement becomes the very practice of the ideal that all human beings are entitled to ongoing medical attention. At this particular medical center, medical staff understanding, comportment, and ski 11, communicate the message that everyone is welcome. It is better to treat people before they get sick. Largely through a network of friends and families, as well as referrals and advertisements, EP has countless times, done

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306 just that. Due to this institution's health care intervention, clients have a greater opportunity to reach their highest potential. It's harder to do that when you're ill. The effect in like a pebble in a placid pond. If for example, one family member comes to EP for a checkup, others may follow. Hopefully the large effect will be to upgrade the potential of an entire community. We have observed that EP health care providers are aware that what people perceive good health care to be does vary by community. I note with interest that in this community, the vast majority of clients have complete faith in the white coated medical practitioners. Suggested medical regimen may not always be followed. But members of the public with which I have been in contact, fundamentally trust that EP doctors and nurses know what they're doing. Clients here, generally do not question or contradict diagnoses or follow up care prescription. I'm not at all convinced that this same unquestioning ethic exists in neighborhoods with different ethnic belief systems. As the literature has suggested, some groups of people may be quicker to try home remedies. For some, traditional ethnic healers may be practitioners of first choice. We recall, for example, in Weidman's (1978) important contribution, that she concluded that ethnic groups may get sick "differently." She and her team interviewed African

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307 American root doctors and their patients as well as Puerto Rican Spiritists and their clientele. It seems that the methods of the care providers are very different because they tie into different world views. Yet what share in common, is their understanding that "curing" their patient involves not only medical intervention, but the bolstering of the sick person's self esteem. Another interesting finding of this work is that the reason a significant number of Puerto Rican women are reticent about seeing a physician has to do with cultural impediments. It is apparently a tradition among Cuban people (Henderson 1990) to be stoic when confronted with family sickness. In the case of Alzheimer disease, the family feels a sense of shame that a blood relative has become "crazy." This feeling of shame is compounded by fear as it is believed in the traditional community, that this seeming "craziness" is hereditary. This fine article demonstrates the need for a culturally knowledgeable social service intervention. Arthur Kleinman (1980) offers persuasive evidence that people's beliefs about sickness and treatment e xpectations are all aspects of their particular social reality. The reader recalls his distinction between disease and illness. I am reminded as well, that a full 7 3 percent of queried people experiencing sickness episodes only received attention from family members and not formal providers.

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308 The physicians at the center are aware of differing ethnic perceptions. They have been documented. For purposes of review, I recall one here. The internal medicine physician who again, is himself African American, spoke of what he referred to as the macho African American self image. The doctor said that many young and even middle aged African American males, view themselves as indestructible. He said that this was not true of similar aged men cross culturally. It was his opinion, that this self image only begins to change "at the first sign of chest pains." This knowledgeable conjecture, suggests a future institutional health care intervention which would primarily impact African American males. We have seen that a majority of EP clients do not have a history of preventive health care. In this neighborhood, food, clothing and shelter have had to come first. This is not likely the case in more middle class white suburban neighborhoods. In EP's neighborhood, good health care has for many, meant that the doctor is available when a child gets sick. New habits of preventive (now affordable) health care, may require sensitive institutional intervention. In this neighborhood, people have lost jobs or for other circumstances, can no longer afford medical insurance. Many here are angry at "the system," embarrassed by their circumstances or for one reason or another, are without hope. Providers at EP know to give them confidence. In this manner,

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309 the Head Nurse told me that a technique she used was to tell clients of all the professional people who come as clients to the center. She said that this information "boosts them up." As explained, the physicians have been quite successful at listening to people's circumstances. They then try to develop confidence levels where they may become the new "family doctor." During the nine months of my internship, I witnessed only five Asian American client encounters. Each incident involved the health of at least one child. Once or twice, more than one child would become the subject of care. But what I thought noteworthy, was tha t in each case, the mother would never walk in with j ust the child. In each case, the father would accompany his wife. This evidence suggested a different family dynamic. Primarily though, EP cared for many single mothers and their offspring. By now, the reader has received a significant accounting of the community services provided. I believe this health center has adapted nicely to the neighborhood distinct health care c hallenges. We have thus far compared a definition of quality health care with the actual circumstances I found at the Evelyn Perry Community Health Center. Before answering that judgement whether EP provides quality health care to its community, our ultimate question, I believe it would be helpful to consider once again some of the germane readings presented in the

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310 literature review of Chapter Two. The authors raised some important issues which I think can better elucidate the context of, and ultimate outcome to, the question of quality health care. Literature Review Comparison Constance P. Deroche (1987) studied a Canadian family planning center. Her article illustrates that an organization is dependent on its larger financial environment. It also shows that the macro environment within which an organization exists, shapes its development as well as its comportment with other community institutions. The community health center comes up for federal review of its basic (Section 330(a)) grant every three years. To continue operating with the aid of the demonstrated essential federal funding, its services must conform to specific regulations. As listed in Health Care. Access and Equality (1990:11), community health centers must : -render health care to a population or area that has been federally designated as medically under served -provide family oriented primary health care which will include basic medical and laboratory services, as well as support in the delivery of preventive health and social services

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311 -be governed by a community based board of directors, the majority of whom will be center patients -be administered by an executive director, responsible to the board of directors -employ highly qualified medical and clinical staff -adjust the cost of their services according to the patients ability to pay -to the extent possible, provide all services under one roof thus emphasizing constituent convenience The description of EP has demonstrated that the federal government has indeed, created the basic rules and parameters of this center's daily functioning. In addition to the need for the operating grant, the center must be Medicare reimbursed. The federal government as well as the states provide the vital Medicaid reimbursements. We have also seen, that the federal government has lent crucial help in funding birthing and well baby classes. It has supported the joint effort HIV center. Finally, it has provided all the money for a major expansion construction grant. So yes, the federal government has made the rules and created standards by which EP must perform. Yet, in response to the Deroche perspective, I am equally interested in the views presented by Billie R. DeWalt and Pertti J. Pel to ( 1985). Again, they are intrigued by the choices made at the "microlevel" by groups and institutions vis-a-vis their "macrolevel" circumstances. I note that this

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312 intellectual outlook well fits a cultural ecological theoretical perspective. In the particular case of EP, the center applied to the federal government for prenatal and Lamaze classes grants. It also applied, along with other local institutions, for an HIV center grant. Why were these particular grants asked for? Well, the numbers of clients with germane symptoms corning through the center door informed the administration that the local community had particular health conditions. I think it likely too, that the Executive Director felt that the addition of these services would strengthen the bonds of allegiance between the center and a burgeoning client population. The federal government had set specific CHC parameters. Yet, these parameters did permit and I believe, even encouraged, local CHC response to community need. Fortunately, there is enough flexibility built into the macrosystern, for this idealto succeed. We have here witnessed pressure from "below" helping the health center to encourage and ultimately engage in community specific policy. These pressures built up over a period of a few years. The way is certainly open for new local influences to shape future EP funding requests. Baker and O'Brien ( 1978), hypothesize that "organizations with highly similar goals will tend to see each other as competitive, while organizations with complementary goals will tend to see each other as more cooperative" (400). During my

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313 internship experience, I believe I have witnessed examples of each of these. I have reported that near the completion of my internship tenure, a for-profit HMO business came to the neighborhood. There was some concern that EP might lose some clients as a result of this challenge. One of the tangible ways EP responded was with comparative public literature. The reader has experienced some of the highlights and its message. The two organizations do view each other as competitors. At the same time, EP was making alliance with a local drug prevention agency and a local university hospital, for the purpose of opening a neighborhood HIV health center. What these organizations had in common was complimentary goal expectations. As such, they worked together, each conceding a degree of control over the project, for the larger common purpose of writing the grant and making the idea a reality. We have also observed that in the northern part of the county, a large hospital and a nonprofit charitable organization were instrumental in helping EP to open a new health center. It was in the interest of the hospital to order its foundation to contribute hundreds of thousands of dollars towards this end. After all, the center would likely serve many non-paying hospital patients. The local charitable organization donated the adjoining building to its headquarters. Therefore, its highly visible name would always, at least indirectly, be associated with the

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314 health center. It would locally show to the community, "your charity dollars at work." The center's existence at this locale permits public demonstration. Finally, in comparing the germane literature to my internship experience, I conclude by again referring to table one. It represented some of the results of The Governor's Task Force on Black and Minority Health (1987). The study was commissioned by The Ohio Commission on Minority Health. The table compared white and African American infant mortality. In categories designated as: infant deaths per 1,000, neonatal deaths per 1,000, and post neonatal deaths per 1, 000, black infants were statistically rated as twice as vulnerable as white infants. It is extremely unlikely that inner city Ohio neighborhoods are the only neighborhoods in America where this racial disparity exists. I believe that EP makes a difference in reducing infant mortality in its community. Issues of prenatal and post natal care were prominent in EP's medical treatment regimen. The center responded to its client's needs. As it happens,.twothirds of its clients are African American. Therefore, it is a virtual certainty that the aforementioned racial disparity is, in this community at least, greatly reduced. It is a virtual certainty too, that there are more happy, healthy babies because of the efforts of this community based medical organization.

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315 Research Question: Experiential Answer The formal research question I posed at the beginning of this tex t was: do nonprofit community health care centers offer quality health care to low income Americans? The results obtained from an in depth examination of a single CHC will not guarantee the accuracy of a generalized sweeping statement. However, as a positive answer from the posed criteria has been ascertained, I believe we can say that at least it is extremely likely that community health care centers have the ability to offer quality health care to low income Americans. I think this one case has broad predictive value. Given the federal requirements of CHC operation, we can recognize many built-in structural similarities between EP and other such health centers. Considering these prescribed similarities, I believe that one can say with confidence that nonprofit CHCs, greatly halp their communities. If a middle sized CHC like Evelyn Perry is any guide, and I believe it is, most centers are likely staffed by dedicated, caring professionals whose first priority is service to people in need. Amid the variety of contemporary health care providers, nonprofit community health care centers offer people of low income, a medical facility of quality, client orientation, and humane spirit.

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316 CHAPTER 7 IMPLICATIONS FOR APPLICATIONS I hope that I have made a convincing case that The Evelyn Perry Community Health Center offers quality health care to its community. Further, this single study can be used to make predictive statements about the quality of care low income people receive at many other community health centers. I believe this is true for several reasons. As we have previously discussed, the federal requirements for start up and continuance of needed funds are rather specific and Recall that among these are rules concerning the basic care to be offered, costs to clients, easy public accessibility, and community representation on the Board of Directors. Annual and broad based three year funding continuance reviews are the norm. More than this, however, I have witnessed the dedication of staff to the relieving of human misery. Many of the EP employees have the ability to receive greater remuneration elsewhere. They choose not to. Instead, they serve in community medicine. They serve this particular community. Yet, these fine people are not unique. Certainly knowledgeable, caring practitioners work in other CHCs tending to people who have few other health care options. Still, other studies need

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317 to be conducted to conclusively demonstrate that this work has predictive value for the quality of care clients receive at similar institutions. In this chapter, I suggest additional needed research. My emphasis here is on helping ethnically diverse populations to receive periodic health care treatment. It is better to treat people before they get sick. I am convinced that applied anthropologists can help. Additionally I will discuss what I believe to be the urgent issue of community interpretation of a deadly disease and how anthropologists can play a critical role in this fact finding within the CHC venue. Further, I recommend consideration of the direct use of applied anthropologists by community health centers. While this kind of direct employment may not always be financially feasible, I offer other means for ongoing anthropological intervention. In this manner, I believe hospitals, medical schools, and universities are appropriate institutions to assume the salary requirements of an applied anthropologist primarily assigned to one or several community health care centers. Also, while relations among local clinics have the potential to become contentious, I believe I can suggest ways an applied anthropologist can change institutional acrimony into cooperation. The importance contemporary public and placement of policy environment CHCs within the shall also be addressed. We will examine how these institutions may be the

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318 appropriate service vehicles to provide humane and efficient health care policy information. Finally, it is to be understood that each of these discussions shall occur within the context of the author's goal of contributing to the further development of the profession of applied anthropologi. Suggestions For Future Research I hope that anthropologists work with other CHCs to determine if they offer quality health care to their respective communities. As we have seen Weidman (1978), Kleinman ( 1980), Henderson ( 1990) et al., the answer t o this question may embody considerable cultural interpretation. Anthropologists can contribute to the success of these institutions by collecting data which could make policy initiatives community germane. Anthropologists are skilled too, at program evaluation. These analyses can contribute to the growth of our discipline. Of special interest to anthropologists would be a in a multi-ethnic urban community. I recall my New York City boyhood neighborhood. Three distinct ethnic groups lived there side by side. The co-habitants were Irish (many then first generation), Puerto Rican, and Jewish. A fairly large proportion of the Jewish population was Hasidic. What a challenge a neighborhood such as this might be for an ethnically sensitive community health center! All of the

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319 described variables come into play such as differing diet, medical belief systems, appropriate junctures for a medical intervention, and familiarity with neighborhood institutions. Immediately a question of accessibility comes to mind. Might this CHC be "conveniently" open on Saturdays? Such an availability would be interpreted as blasphemy to the strict Hasidic community whose weekly Sabbath begins at sundown Friday night and extends until sundown Saturday. It seems that urban multi-ethnic communities offer a rich opportunity for sensitive data collection and policy evaluation. Another related policy arena for anthropologists working in the public health center environment is the comparison between populations served by urban as opposed to rural centers. Some early work here (Bezon 1992) points to some differences in such issues as population survival skills, medical belief systems, and accessibility. I believe that on site urban versus rural anthropological studies should be encouraged. A question which interests me is the perception by communities of the legitimacy of the care offered by western trained health care practitioners. We have seen that in this particular study, CHC doctors and nurses enjoyed nearly unquestioned prestige. But this attitude is not universally shared. I believe this to be an important area of continuing research within the profession of anthropology. Local answers to this question will greatly impact the healthiness of entire

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320 communi ties. Analogous areas of future research include a study of local home remedies and the influence and techniques of traditional healers. These areas of study and recommendation have for decades, been part of the venue of applied anthropology. Members of our profession have demonstrated proven on site skills of observation, data reco"rding, analysis, and guiding counsel. This work has been achieved for the most part within an understood environment of providing respondents and their beliefs the fundamental respect they deserve. If this kind of research may be pursued from the position of a CHC level employee, the health care of studied communities would be advanced. The profession of applied anthropology would also be the beneficiary ofimportant new information. I'm afraid there is urgent need for work on behalf of HIV positive and AIDS patients. As discussed in the last chapter, ways must be found to reduce the prejudice and fear of homosexual AIDS patients on the part of medical care givers. Further, it is important that we know what the disease "means" to members of different cultural groups. An example of obtaining this most personal of illness information is provided in Patricia L. Salmon's Women' s Narratives: Living With HIV Disease (1993). By means of life histories and actual patient drawings, the anthropologist was able to learn what the disease "felt like'' to twelve AIDS afflicted women.

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321 This type of information will aid care givers in their task of reducing suffering for clients and their loved ones. At the very least, it can provide the added depth of the patient' s personality to the care giver-care receiver relationship. Specifically, if medical providers could become acquainted with life histories, their understanding of the patient as merely a biological being would be shattered. I believe a more knowledgeable and empathetic provider-patient relationship would result. Further, I would envision a fuller intervention to relieve the suffering of grieving friends and family. A helpful guide in how to achieve this was offered by Henderson (1990) as he wrote about an intervention on behalf of senior Cuban women whose husbands had become afflicte d with Alzheimer disease. His research had indicated that the studied Cuban community had traditionally dealt with sickness stoically and alone. He also learned that among this population, the Alzheimer patient was considered to have become "crazy." Families felt a sense of shame concerning their loved one's condition. Worse, it was also believed that the disease was carried in the blood and was therefore hereditary. It was decided that one way to help was to get the embarrassed and stressed-out wives to talk to women in similar circumstances. However, talking to strangers in a group created by social service intervention had not been habitually familiar. Therefore, to bridge this gap the eldest daughter

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322 would accompany their mothers to the support meetings. It was believed that the younger women would have had more experience with social service interventions. This belief proved to be accurate. Yet, as the mothers became more comfortable with these meetings, it was found that they would eventually come to the meetings alone. These senior women were bonding as their own support system. They made new friends as they gained clinical knowledge and shared their stresses and their fears. I would like to see similar kinds of research conducted with the help of HIV afflicted people. An understanding of the meaning of the disease to patients and affected family members and friends, can go a long way toward making a terribly grievous situation more bearable. I think such a data-finding-mission and planned intervention should be carried out from the perch of an HIV oriented community health care center. Employed Applied Anthropologists Serve Community Health Centers To efficiently assist the development of community health care centers, that is, to keep these institutions attuned to community needs, they should have available to them a full time culture broker. The best trained person to fulfill this role would be an applied anthropologist. A few CHCs might

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323 individually have the f inancial resources to hire thei r o w n applied anthropologist. I think in most cases, however, these practitioners will be employed by cooperating institutions or alternately, their salary might be cooperatively shared. One such participating institution might be a local hospital. In my experience, hospitals do form symbiotic relationships with CHCs. Hospitals often donate equipment (a tax write off), personnel, and even offer start up money to these centers. In return, the health centers service the neighborhood's financially least equipped people. Rarely can hospitals care for this population in an efficient manner. Quite simply, with non payers they always lose money. I envision a hospital employing an anthropologist to work on behalf of numerous community health centers. This appointment would have pragmatic intent. The applied anthropologist would help CHCs spot additional low income populations which could most efficiently be served by these institutions. This employee would advise health centers on means to encourage repeat visits by low income populations. I believe the new patient habit would be appreciated by most hospitals. As hospitals would not have to take on f inancially burdensome patients quite as often, they would appear to be amenable (as this study has found) to admitting CHC recommended clients for free or low cost specialized care. I note that this occasional CHC admission is far preferable for them than a full onslaught of non-paying patients.

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324 Medical schools might also be similar employers. First, I think an anthropologist working at a medical school and a CHC, could help the school gain access to grant money which might not be available to a hospital-only connected institution. Second, an applied anthropologist could hopefully teach a course in community medicine at the school. Early on, the doctors in training might become acquainted with the perceptions and sensitivities of people living in the medical school's neighborhood. The local CHC might then become a requested posting for advanced students to receive training. Another advantage to the school and its students is that a career path of community medicine might become a viable option. But I think the most important contribution that the applied anthropologist could make is to help produce better doctors. By this I mean, physicians would learn to more easily consider people as individuals with very personal and cultural perceptions concerning their own interactions with the medical establishment. The medical schools would produce more able and respected physicians. The new physicians would be better trained. Ultimately, the general public would be receiving better care. I would urge the adoption of this win-win-win suggestion. In similar spirit, I recall the accomplishments of anthropologist Hazel Weidman (1978). Working at the University of Miami, and by forging ongoing relationships at the medical school she and her research team were able to increase the I

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325 level of community communication between numerous diverse ethnic populations and their local clinics. The result was often improved levels of health care for some of south Florida's low income population. The for this result can be found in her project's purpose. She said, "our ultimate goal is ... to make the formal health care system more meaningful to various populations in the light of their own traditional health cultures and healing modes" (1978:868). An applied anthropologist employed by the university and working in a CHC could also make each institution aware of mutual grant possibilities. Further, universities would gain invaluable data about the people living in the communities where they are situated. Community relations with noncollegiate residents has been represented in the media as an ongoing challenge. Another benefit of this employment is that the anthropologist would be able to teach students from a dynamic applied perspective. What a boon it would be to the teaching of medical anthropology. I have been privileged to enjoy the wisdom of professors who were currently engaged in offcampus-projects. The wisdom of these scholarly problem solvers has helped to shape my way at looking at the world. I also think that the dual employee would be the perfect person to help forge a health care relationship between a university and a CHC. In many universities, students have the availability of a medical infirmary. But in most cases, a CHC

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326 is better equipped and better staffed. A university may save money contracting out to the CHC to cover their student's medical ills. It would be likely that they would be permitting their students a higher level of ongoing medical attention. It lS conceivable that from time to time, relations between medical institutions primarily geared to serve low income people could become contentious (Baker and O'Brien: 1978). Community health centers as described, would not likely have this problem. As we have said, the federal government ultimately decides by needs assessment which potential centers will receive funding. Also, there simply are not that many of them. But other institutions such as independent or hospitalsponsored "free clinics," could potentially become a CHC rival. An applied anthropologist can do much to turn a possibly acrimonious relationship to one of mutual benefit. For example, with researched knowledge of the common community, the practitioner can advise each organization of their most effective client niche. In this manner, one center might choose to concentrate on women and children. Another might feature a more geriatric care orientation. The anthropologist could seek further benefits for this arrangement. For example, they could pursue grant money for a neighborhood three-generation-study. Analysis of local health conditions for seniors, offspring, and their children could include several health centers.

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327 The centers could be advised as to which advertising media would bring them the most clients for their money. Advertising could be shared. The costs would be too. Guided cooperative programs between institutions could become habitual. I might envision, for example, a seniorchild story telling time. Similarly, several clinics could cosponsor community events. Street fairs might include separate but germane free medical testing. Also, inter-staff softball games. might be a great way to work off case load stress. The question of who might hire such an anthropologist is appropriate. The answer it seems to me is that it would benefit all of the aforementioned potential employers to hire a practitioner for this cooperative institutional task. In this way, numerous health centers would reduce their salary burden and improve their community responsiveness. Hospitals would benefit in the way of further reductions to their low income patient load. Medical schools would gain additional knowledge of their neighborhoods and would be able to provide their students with more community medicine service opportunities. University programs would also add to their knowledge base. Their ability to carry out more grant directed requests would also be enhanced. We have witnessed how EP responded to the particular needs of its clients. Prenatal and well baby programs are two examples. Dewalt and Pelto (1985) have helped to illustrate

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328 that within permissible macro program parameters, local institutions can take meaningful initiatives. This is one area in which an applied anthropologist can help a CHC. Applied anthropologists are well equipped to help community health care centers meet the needs of their constituents. To ensure an institutional-community fit, anthropologists could devise means to measure whether case load demographics approximate neighborhood characteristics. They might learn ways to decrease appointment no-show rates. It would be helpful practice to determine why some clients simply walk away from the ongoing care option. Anthropologists could also monitor levels of consumer satisfaction. They could be informative about changes in neighborhood health conditions and suggest effective means to ameliorate problems. Anthropologists can develop criteria to measure effectiveness of service. Working with physicians, for example, anthropologists could design ways for the institution to learn of service improvement outcomes. Further, the ongoing effectiveness of the local CHC social service programs could be measured and then either enhanced, altered or eliminated. Anthropologists employed by community health centers may also seek out other community and even national organizations with complementary goal expectations. Research may aid the anthropologist to discern which groups might find it in their best interests to join forces, with the result being community benefit. That is, the anthropologist could conceive of inter-

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329 organizational relationships which might strengthen each member of said coalition for the purpose of common service. The advocate might also conceive of a community project which could best be handled by a multitude of member groups. The project idea can be presented. The relationships can be formed. Funding candidates would be identified. The consortium could then apply for necessary funding. Their relationship would be more likely to persuade a would be granting institution that the amalgamation could actually achieve their prescribed goal. Then together, various entities could work for the common ideal of establishing and maintaining the new project. Anthropologists would be appropriate social scientists to. seek out community organizations. We would learn who the powerful people in those organizations were. These organizationally powerful people may not be structurally obvious at first glance. For example, we have learned (Peterson: 1990") that church "Mothers" are powerful women indeed, in the "black" pentecostal church. These women have achieved their influence as a result of long term demonstrations of faith. As an example of their power, they often have at their disposal some rather significant parishioner-donated financial resources. The largess is then distributed along prescribed network routes. Therefore, to have these women as health t ll ( a Board of Directors seat or active cen er a 1es 1e.

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330 volunteers), may be more helpful than a similarly engaged Church minister. It is critical to know how information is passed along in particular neighborhoods. For example, in a studyamong older African Americans (Rao and Rao: 1983) living in Jackson, Mississippi, it was found that women made use of local social service opportunities as a result of hearing about them from work colleagues. Older men on the other hand, were likely to use these same social services if they rated their "life satisfaction" as high, or if they were prone to accepting familial aid. At the center where I worked, most clients were motivated to come by friends and family. This, of course, is invaluable information. But beyond this knowledge it is helpful in a study such as this to know that in many African American communi ties, the term "family" can have a broader meaning than it does among other ethnic groups. Research conducted by Johnson and Barer (1990) demonstrates that African Americans will reach to the very edge of their family systems for aid and support. This perspective is in contrast with, for example, white groups who traditionally have a more narrow aid focus. Elongated familial contact is found to be far more frequently employed by African Americans. This same research also indicates that African Americans have a propensity to graft good and helpful friends onto the

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331 family tree. Thus, fictive kinship terms such as "sister" or "brother," are used as terms of endearment. As these perceptions of family seem to exist in many African American communities, outreach employees of community health centers may have many potential allies i n their efforts toward bringing potential clients into the centers. It would be ideal if in low income communities of all ethnic makeup, community health centers could be perceived as a trusted family friend.

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332 CHAPTER 8 COMMUNITY HEALTH CENTERS IN THE EMERGING PUBLIC POLICY ENVIRONMENT On November 8, 1994 the American people voted in a new Congress with a very different agenda than that conceived by the office holders they replaced. The change was politically stunning. The biggest change was in the House of Representatives. In this body, the Republican Party took over working control of this institution for the first time.since 1954. The election results in the Senate were nearly as significant. The Democrats who had in the last Congress enjoyed a comfortable working majority, lost voting control of that body as well. A new political day had arrived in official Washington. struggles Old and New As the political landscape has been considerably altered since the beginning of this work, I think it is necessary to discuss community health care centers in light of new political realities. Amidst the backdrop of the political sea change, I identify two different but obviously related

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333 struggles. The first is old news for this author but it remains critical. I believe in the continuing struggle to try to make the lives of low income people better by at the very least, providing them with local, affordable health care. The second struggle is new. It presents artful challenge. This second struggle is to get a majority of the newly elected Congress to care about the interests of poor people. This task is not simple because we have heard that the new Congress was elected amidst the "rage of white suburban males." We are told by contemporary political analysts that this rage is directed against big government and concomitant special-interest "give away programs." Community Health Center History Review In the mid-1960's amidst the sweeping political power of the Great Society, evidence grew for medical observers that "health care was still essentially a privilege with a price tag" (Geiger:l984:11). For the poor, that often meant that it was unavailable, inaccessible, inappropriate in its organization and focus, or ultimately ineffective in its delivery. In response, the Office of Economic Opportunity proposed the neighborhood health center program. To be sure, health care at these planned institutions was to be offered

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334 inexpensively. But the program emphasized additional and much wider goals. These aims included, shifting the locus o f services from hospital to local community, and the emphasis from complex tertiary care to primary care. They also included new patterns of professional organization such that an emphasis would be placed upon multidisciplinary teams that consisted of paraprofessionals recruited from the target neighborhood population. Part of the CHC ideal was to also broaden the scope of "medical" services to include health-related environmental and social concerns. Finally, these centers were to provide means of giving low income people an assured role in the design and control of their own health services (Geiger 1984). Even beyond this new definition of the delivery of health care, CHCs were viewed by policy planners as part of systemic social change. Planners wanted to confront social and political determinants of health status that existed in the social order. It was argued that "health care services should be deliberately used as a point of entry for such broader social change" (Geiger 1984:13). The policy planners envisioned CHCs as turn key institutions which would habitually refer clients to many other institutions which also delivered community accessible social services and were too, created and designed by neighborhood people. Some of the discussed alternativ e

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335 institutions included community food coops, child day care centers, cannery businesses, and community gardens. Community health care centers were but one institution albeit a major one, which would eventually help local people take control of the institutions which often affected their lives. This was the envisioned definition of "community empowerment." Community Empowerment to Family Values Administrations in Washington may come and go. Congress may even experience political upheaval. But one thing never changes, Washington's propensity to create fashionable phrases. Thirty years ago, the catch phrase was "community empowerment." Today, we hear that what this country needs is a return to "family values." An interesting question is whether these two phrases imply similar community health care policy outcomes. This question can best be answered if I at this time propose program suggestions which in my judgement can be well carried out today by community health care centers. Ideally, it would be helpful to learn what the phrase "family values" means to many incoming Congressional members. In anthropology we know that it is often critically important that practitioners be on site to glean the meanings of symbols to participating populations. Oh, what I wouldn't give to be able

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3 3 6 to perform even a "rapid appraisal" of the meaning of family values to freshmen members of Congress. Though rapid appraisal was a concept originally conceived as a tool for measuring the appropriateness of rural development projects, I think it would be applicable here. With its combination of the use of systems perspective, triangulation, and iterative data collection and analysis, I think it would help our study. For our purpose of an informative Congressional "snapshot", I appreciate that "rapid appraisal can be thought of as an open system using feedback to 'learn' from its environment and progressively change itself" (Beebe 1995:48). In this way, an appropriately chosen interdisciplinary research team would, I think, act as an informative guide to program creation possibilities. As this ideal is outside the parameters of the present study, I believe I can here suggest that there are program types which contemporary political leaders would do well to support. Depending on community need, CHCs can instruct people on such health related issues as: personal hygiene, the importance of proper diet and exercise, the dangers of drug or alcohol abuse, and the means to peacefully resolve potentially violent familial circumstance. The advantages of sexual abstinence and, failing that, the use of condoms, in this time of HIV infection will be community informative. community health care facilities can be regularly used to teach high school students effective study habits.

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337 Unemployed people can learn here how to apply and interview for a job. Social service instructors can demonstrate how to create an effective resume. These centers even have the ability to schedule job fairs where clients may be interviewed by potential employers. Community health centers can easily provide the environment where in the words of a popular metaphor, you can "teach people how to fish rather than handing them their supper." Noticeably, each of these suggestions, are fundamentally supportive of family values. Therefore, an investment in community health centers can be viewed as a contribution to more stable families. We can see that the terms "community empowerment" as used by early Office of Economic Opportunity policy planners and "family values" do imply somewhat different health care policy outcomes. Again, community empowerment as discussed, refers primarily to low income neighborhood people assuming managing control of many of the commercial and social institutions w hich effect their lives. Family values as used in this context, implies somewhat different outcomes. our understanding of the term (without now spending actual time with new Congressional members) leads us to consider how we can "sell" CHCs on Capitol Hill. I believe if we present them as institutions where the advantages of sexual abstinence can be taught in an inner city community, we would have an attentive audience. The same result would occur I

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338 think with the related instruction on drug or alcohol abuse, job interviewing skills, high school study habits and even family conflict resolution. In this contemporary scenario, local people do not assume policy control of community institutions. Instead, these help programs lead recipients to be more effective candidates for private sector employment. Whether good paying jobs are made available using this scenario is another discussion. But certainly, on.top of inexpensive community responsive health care, CHCs in the contemporary political universe can with federally supported help programs, improve the lives of low income people. I think under the banner of "family values," CHCs can continue to perform valuable There is another common phrase which is powerful and very understandable to our Congressional decision making audience. That phrase is "cost benefit analysis." As has been carefully discussed in this text, CHCs are federal investments which pay for themselves. They pay back in visits not taken to the local emergency rooms. They pay back upon the delivery into the world of more heal thy babies. In addition to the joy they bring parents and loved ones, healthy babies mean less expensive medical bills later. The centers pay back as well, with a more healthy citizenry who are more often able to work. Ultimately, they wind up saving our cherished suburban tax payers money. Now that sells!

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339 Community health centers provide present policy makers with yet another philosophically tempting lure. Today, we hear a great deal of frustration concerning the failure of Washington planners to effect helpful policy. Community health centers offer alternatives to the more traditional and presently unpopular "beltway knows best" approach. The acquisition of Urban Initiative Funds within established national parameters, permit CHCs to serve their communities in ways which are locally responsive. In the case of the center where I worked for example, a consortium of local institutions was awarded federal money to try and respond to a relatively high frequency of HIV contraction among low income African American males. While I was present, the consortium and the health center were forced to alter their HIV candidate recruitment plans. The change was necessary as unforseen issues of confidentiality negatively impacted the program's designed intent. As this brief example illustrates, community health centers have great potential to provide invaluable data in the formation of efficient and powerfully effective public policy. Data may and likely will be different, per neighborhood and per problem. But I expect that quantifiable trends will emerge. Given today's specialized data bases, public policy can be informed from the streets up, rather than from a Washington based edict. Community health centers can therefore contribute to powerfully effective public policy. Further, as

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340 the potential for program misappropriation is reduced, CHC cost effectiveness becomes even more impressive. The Legislative Agenda One might imagine a reader observing that this sounds all well and good but given the current political climate, isn't this CHC political survival guide just a pipe dream? Perhaps not. I am informed by a piece of legislation that got dozens of co-signers in the last Congress. The legislation is called The Community Health Improvement Act of 1993. It was introduced by Congressmen Michael Bilirakis (R) who represents a district on Florida's west coast, and J. Roy Rowland M.D. (D) of Georgia. The bill would establish demonstration projects which would allow states to work with local communities to develop coordinated health care delivery networks. The networks would be known as Community Health Authorities (CHAs) and they would be comprised of federally qualified health centers (ie. prenatal clinics), rural health clinics, public health departments, hospitals, group practice offices, and private physicians. The CHAs would be governed by a local policy board, whose members would include local health officials, civic leaders, elected officials, and residents of the area or population being served. At least 51 percent of the board must be

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341 comprised of individuals enrolled in the CHA. The CHAs will primarily focus on serving geographic or population groups which are designated as medically underserved or having a shortage of health care professionals. Medicaid eligible individuals or families will be enrolled. Community Health Authorities may also enroll individuals who do not qualify for Medicaid, provided their income is less than 200 percent of the Federal poverty level. The services provided by the CHA will focus on primary, preventive and acute inpatient and outpatient care and as the bill specifies, "should be tailored to the identified needs of the local comm unity" (Bilirakis and Rowland 1993:2). These Community Health Authorities will be required to provide information to enrolled individuals about other available local programs. Under the bill, each CHA must establish a continuous community health status improvement process to identify and investigate community health problems and implement measures designed to remedy them. They are further required to create quality assurance guidelines that stress health outcomes. They would also submit an annual report on its operations to the state. The state would enter into an annual contract with the CHA and make monthly payments for covered services. states would provide support (with matching Federal funding) for CHA initial planning and development. These expenditures would pay for such CHA needs as: data collection

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342 designed to measure changes in patient access to care, the quality of care furnished and patient health status, and ongoing community outreach and education. The bill in large measure gets us to our policy goals. This author, in the present environment, would only quibble with the CHA planned funding source. In my view, it is preferable to continue to emphasize federal support for community health care centers. State governments have traditionally varied greatly in their commitment to social service funding. One reason, of course, is that some states such as New York or Pennsylvania have large populations who pay a somewhat progressive personal income tax. Other states such as Mississippi, or Alabama have smaller, poorer populations. It is also true that states have demonstrated differing historical commitment in the help they provide their low income citizens. Again, benefits provided by New York and Mississippi are not the same. The final concern is very practical. It is fine in theory to turn the primary financial responsibility for low income health care over to the states. It sounds as if there is potential for greater local control. But one must ask how many of the new Republican governors would really want this responsibility given their already tight state budget conditions. I think health care delivery for low income people would suffer under this formula.

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343 Still, given our prescribed policy goals, much of the Community Health Improvement Act of 1993 has merit. As this bill was not generally known by the public, the reader has by now surmised that it died a quiet death after the Clinton Administration refused to sign on to the plan. Is this legislative rendition then part of the same pipe dream? Well now in 1995, Republican Congressman Bilirakis is chair of the House Health and Environment Sub Committee of the Commerce Committee. He is presently holding hearings on these health delivery matters. A bill is expected to be reported out of committee later this year. Changes Indicated by this Research This study provides evidence favoring the proliferation of community health care centers in the United States. The numbers of such centers must grow in communities with demonstrable health care need. The primary service population should be low income people. Increases in federal funding to these institutions is the way to achieve that objective. As federal funding is viewed in the various communities as habitual, the health centers will be more readily perceived as community institutions of permanence and reliability. Because of this, their ability to serve low income and often health vulnerable populations will be enhanced.

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344 It is important that a systemic plan towards these ends be understood and implemented. The increase of federal funding to the centers is one step. The ability and persistence of the centers in obtaining state, local and private grant financial support must continue. This diversity of funding and association is very important, but crucial is increased federal funding for CHCs while at the same time maintaining the autonomy of local policy making. Community health care centers have been around since the mid 1960's as they were given their start as federally funded experimental "demonstrations" during the Johnson Administration. During the 1970's, their numbers grew. By decade's end, their number had reached nearly 800. Yet, in the 1980's and early 1990's, the number of community health centers has declined. Presently, there are fewer than 550 such health centers nation wide. One reason for this numerical decline is that the funding environment was changed. The rate of increase of federal funding support during the last decade, lagged behind spiraling medical costs. Further, in the 1980's, the federal government, in cooperation with many state governments, made Medicaid requirements much more difficult to meet. Most states refused to pick up the slack so that fewer people would be so covered. As it was harder for people to qualify for means tested federal-state assistance, it meant that community health

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345 centers would not as often be reimbursed for performed medical service. Therefore, the newer funding environment was less permissive of the birth of community health centers. The macro political environment can certainly negatively impact local community institutions (Deroche 1987). Sadly, this systemic impairment has retarded the adcess of low income people toward the chance for CHC administered health care. This obstacle has also as demonstrated, cost everyone money. Below the level of institutional survival, there are other areas where increased federal support is also essential. For example, this study has demonstrated the need for increased funding for CHC social service and outreach employees. Next, I will discuss what I believe to be a desirable change of behavior on the part of a federal government department vis-a-vis the birth and growth of future community health care centers. Then on a different but related subject, I will show support for the increased funding and fine tuning of the National Health Service Corps program. The data indicate that the addition of the salaries of social service employees and institutionally designated outreach employees, over and above the basic CHC federal funding would benefit community residents, the participating institution, and the tax paying public. Presently, these employees are paid by the local health care center. That is fine, but the salaries represent a subtraction from the

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346 center's overall budget. Therefore, not many such employees can be hired. The health centers cannot afford this luxury. This constriction is not helpful. These employees provide humane service. Pragmatically, their worK is cost effective. This is true because they presently act as conduits to bring the medically and sometimes socially disenfranchised into a system of help and hope. Social service staff connect people to ongoing medical attention. They encourage young mothers to bring their children to the health centers for checkups. They advise high risk populations about how they may prevent their contracting communicable disease. These dedicated employees more than pay their way. If their salaries were added onto the basic federal operating grants, and if there was provision for an entire social service staff, they could make a more profound community impact. The impact would be most powerful if social service assistance were planned on a local community by community level. For example, with the background of a patient satisfaction survey, I learned that 27 percent of the CHC client base where I worked said "there was no need" to be annually examined. That "no need" category is broad and will likely have different meanings in different neighborhoods. Could it mean that "I never get sick so I don't need to see a doctor?" Might it mean that a patient has a more culturally traditional medical belief system and is quite happy with for

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347 example, the neighborhood spiritist? Could the statement of "no need" be misleading? In the actual survey, for example, I wanted to learn why people did not come in for annual checkups. One of the major reasons given was that people could not afford it. Even so, I suspect that in many circumstances, some people would be ashamed to write that. Therefore, they might claim lack of need. If however, neighborhood residents were informed that community health centers provided low cost care, they might in fact, develop "a need" to seek out an annual preventive checkup. The depth of the answer to the 11no need11 question must be learned from the clients of the health center. As importantly, it must be learned from the community majority who have never traversed the health center's door. This real life example, demonstrates that local professional interpretation of this survey response must be understood to reflect community health care circumstances. A constructive change in the delivery of information on the part of the Department of Health and Human Services is called for. It should be proactive in informing low income communities about the availability of Urban Initiative CHC start up funds as well as the concomitant rules and regulations. Perhaps informative brochures could be designed for local library, community center, public housing and post office distribution. A standard ad can be prepared to run in neighborhood newspapers. Public service announcements can air

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348 on known locally popular radio stations. This information may engender active community participants to coalesce, organize, and then apply for CHC funding and formal designation. Presently, there is a helpful program in place called the National Health Service Corps. The service corps plan permits physicians just out of medical school to repay their loans by working for a period of three years in a facility such as a community health care center. This policy helps CHCs to afford physicians. Therefore, as this study has documented the value of CHCs, it is essential that increased federal funds be made available for this ongoing program. Most of these doctors are well qualified and do a fine job. But 70 percent leave after their three year commitment. One reason for this turnover is due to the program's design. Presently, when a new doctor finishes residency and applies for the service corps, they are assigned three geographic locations. They may choose one. This is a cause of the turnover problem. Several physicians presently so enrolled have told me that they resent the lack of choice. After all, they are being told where to practice their livelihood. Also, three years away from people and things familiar is a long time. Another cause of the high turnover rate has to do with the relatively low number of minority physicians. Minority physicians have had a higher propensity to practice community medicine than their white colleagues. Also, as this study has

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349 shown, many minority health professionals are aware that they are themselves role models in communi ties often bereft of hope. In response, minority candidates should be actively recruited by American medical schools. In my opinion, the medical school at the City College of New York represents an excellent example of an appropriate open door policy. The National Health Service Corps program's three choices policy deserves a response. A needed improvement might be a rule change such that physicians who have completed their training would be permitted to choose as a fourth service option, the community from which they came. This might be the community where they were born or from where they applied to college. I do believe, such a policy change, combined with the reemphasis of the teaching of primary care medicine, would coax many of these physicians to stay in their neighborhood of service. If given this fourth choice, many of these doctors would likely enjoy giving something back to their communities. Particularly if the Department of Health and Human Services adopts this rule change, the increase in funding for the National Health Service Corps would provide broad societal benefit. Conclusion community health centers are a perfect fit in today's complicated mix of health care delivery systems. They are cost

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350 effective. They often serve i n symbiosis with larger, financially beleaguered main stream med ical institutions. They are usually better equipped than more structurally rigid health care facilities to reach at risk people "where they live." Community health care centers are also nimble enough to join with other helping organizations to perform health care provision which can be particularly community germane. Consider too, that despite the percentage decrease in CHC earmarked federal spending, and the increase in Medicaid obtainment obstacles, most centers continue to grow. There is obvious need. That need is annually growing. The raw numbers of medically vulnerable people merely hint at a severe societal problem. When you work among hard pressed human beings who are doing their damndest just to survive, you realize how valuable these institutions are. Now at the end of this study, I remind the reader that our purpose was to try to improve the lives of low income Americans. our thinking was that when people were physically well, they had a greater opportunity to lead fuller, more productive and happier lives. Before my on site internship, and more profoundly after it, I fundamentally believe that just because a human being happens to have a low income, it doesn't mean that they are not entitled to quality health care. I reiterate an Evelyn Perry staff pediatrician's statement which says it best; "just

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351 because you're poor, it doesn't mean you have to stay home and watch your baby die." Community health centers can help prevent this kind of moral obscenity. They can at the very least improve the physical health of this country' s low income people. As shown, they have the potential to do much more. We have witnessed in this work that community health care centers can provide their clients with quality health care. They further improve the chances that a variety of medically at risk populations can be helped. I am an advocate.

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366 Vierck, Elizabeth 1990 Paying For Health Care After Age 65. Santa Barbara: ABC-CLIO Waitzkin, Howard 1983 Community-Based Health Care: Contradictions and Challenges. Annals of Internal Medicine V .98 No.2:235-242. Weidman, Hazel H. and Janice A. Egeland 1973 A Behavioral Science Perspective i n the Comparative Approach to the Delivery of Health Care. Social Science and Medicine V .7:845-860. Weidman, Hazel H. and Janice A. Egeland 1978 Miami Health Ecology Report. Volumes 1&2. Miami:University of Miami School of Medicine. Whiting, John and Beatrice 1973 Methods For Observing and Recording Behavior. In A Handbook of Method in Cultural Anthropology R Naroll and R. Cohen, eds. Pp.87-109. New York: Columbia University Press. Wiley, Andrea S. 1992 Adaptation and the Biocultural Paradigm in Medical Anthropology: A Critical Review. Medical Anthropology Quarterly V.6 No.3:216-236. Wilkins, Alan L and William G. Ouchi 1983 Efficient Cultures: Exploring the Relationship between Culture and Organizational Performance. Administrative Science Quarterly 28:468-481. Wi lliams, Brett 1992 Poverty Among African Americans in the Urban United States. Human Organization V.51 No.2:164-171. Williamson, John B., Linda Evans and Lawrence A. Powell 1982 The Politics of Aging. Charles C Thomas: Springfield, IL . Williamson, John B., Judith A. Shindul and Linda Evans 1985 Aging and Public Policy. Charles C Thomas: Springfield, IL . Wilson, Robert N. 1970 The Sociology of Health. New York: Random House, Inc ..

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367 Wolfe, Alvin w. 1977 The Supranational Organization of Production. Current Anthropology 18(4):615-636. 1980 Applications of Network Models To Drug Abuse Treatment Programs. A Brief Review Paper. Connections 3(2):28-29. 1981 The Uses of Network Models in Health and Human Services. Paper presented at the Sunbelt Social Network Conference. Tampa, FL .. 1982 Forward. In Case Studies in Applied Anthropology Internship Training. Michael v. Angrosino ed. P V Tampa: Human Resources Institute Monograph Series Three: No.9. 1984 Network Models of the Urban Environment. Paper presented at the 82nd Annual Meeting of the American Anthropological Society. Denver, co .. 1987 Levels of Integration in Networks of Urban Agencies. Paper presented at the Meeting of the Society for Applied Anthropology, oaxaca, Mexico. 1988 Network Perspectives on Public Administration. Paper presented at the Annual Meeting of the Society of Applied Anthropology, Tampa, FL .. 1988 Papers on Network Models. Tampa, FL : Center for Applied Anthropology, University of South Florida. 1991 Network Models and Informal Economies. Paper presented at the 11th Annual International Sunbelt Social Network Conference. Tampa, FL .. 1991 Network Models and Their Applications. Tampa,. FL : Center for Applied Anthropology, University of South Florida. Wolfe, Alvin W. and Gilbert Kushner 1993 Applied Anthropology At The University of South Florida. Practicing Anthropology V.15 No.1:3-6. Young, Allan 1978 Rethinking The Western Health Enterprise. Medical Anthropology V.2 No.2:1-10.

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368 COMPANY, GOVERNMENT and GROUP REPORTS American Cancer Society 1993 Cancer Facts and Figures-1993. Atlanta, GA .. Association of State and Territorial Health Officials 1992 ASHTHO Bilingual Health Initiative. Washington, D.C .. Best, AM & Co . 1989 Best's Aggregates and Averages: Life-Health. Hawthorne, New Jersey. Bilirakis, Michael and J. Roy Rowland 1993 The Community Health Improvement Act of 1993. Congress of the United States. House of Representatives. Washington, D.C .. Citizens Fund 1990 Premiums Without Benefits: Waste and Inefficiency in the Commercial Health Insurance Industry. Washington, D.C .. Clinton, William Jefferson 1993 Presidential Address to the Nation Outlining the Clinton Health Care Plan-September 15, 1993. Consumer Reports 1990 The crises in Health Insurance. Part 1 v. 55 No.8: 533-548. 1990 The Crises in Health Insurance. Part 2 V.55 No.9: 608-617. Florida, The State of 1990 Florida Cancer Plan-Initiatives For the Future 1990-2000. Tallahassee: State Health Office Department of Health and Rehabilitative Services. Florida, The State of 1990 Florida Morbidity Statistics 1990. Tallahassee: Department of Health and Rehabilitative Services. Florida, The State of 1991 Aids And Other Sexually Transmitted Diseases-1991 Annual Report. Tallahassee: Department of Health and Rehabilitative Services.

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369 Hutqhins, Vince and Charlotte Walch 1989 Meeting Minority Health Needs Through Special MCH Projects. Public Health Reports-Journal of the U.S. Public Health Service V.104 No.6:621-626. Knox, Holly 1992 Automating a Community Health Center: One Organization's Experience -North Florida Medical Centers, Inc .. A Study for The National Association of Community Health Centers. Washington, D.C .. Lacey, Loretta Pratt, Clyde W. Phillips, David Ansell, steven Whitman, Nyambi Ebie, and Edwin Chen 1989 An Urban-Community Based Cancer Prevention Screening and Health Education Intervention in Chicago. Public Health Reports-Journal of the U.S. Public Health Service V.104 No.6:536-541. National Association of Community Health Centers 1990 Health Care, Access, and Equality. Washington, D.C .. 1991 Community and Migrant Health Centers: A Key Component of the u.s. Health Care System-Overview and Status Report 1991. Washington, D.C .. 1991 The Future of Community Health. Washington, D.C .. 1991 Health Care for Latinos: A Bibliography. Washington, D.C .. 1992 Access to Community Health Care. Washington, D.C .. 1992 Lives in the Balance: A National, State, and County Profile of America's Medically Underserved. Washington, D.C .. Ohio Commission on Minority Health 1991 Moving From Vision Toward Victory. Columbus. Ohio, The State of 1987 The Governor's Task Force on Black and Minority Health. Columbus. Primary Health care Consortium of Dade County Inc .. 1991 A Family Health Center Reaches Out To Ne1ghborhood Children and Schools. Miami. Primary Health Care Consortium of Dade County Florida, Inc .. 1992 Primary Health Care Consortium of Dade County Florida, Inc. Miami.

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370 Primary Health Care Consortium of Dade County Florida, Inc .. 1993 Primary Health Care Consortium Hotline Report. Update 3: Miami. Public Citizen Health Research Group 1993 Managed Competition Is Not The Health Care Cure. Washington, D.C .. U.S. Department of Health and Human Services 1989 330-Funded Community Health Centers Directory. McLean, VA: National Clearinghouse For Primary Care Information. World Health Organization 1994 Constitution of the World Health Organization. Washington, D.C .. Yang, Yih-Ming, Arvind K. Shah, Marlene Watson, and Vipul N. Mankad 1995 Comparison of Costs to the Health Sector of Comprehensive and Episodic Health Care for Sickle Cell Disease Patients. Public Health Reports-Journal of the U.S. Public Health Service V.110 No.1:80-86. INTERVIEWS Geiger, Jack H. M.D. 1994 November 20 The ultimate designer of the U.S. and South African community health care center systems (1964 Tufts Medical School). Haendel, Ann 1993 June 29 Project Officer-Office of Health Affairs, Office of Economic Opportunity 1967-1972, Washington D.C .. VIDEO PROGRAMS Brokaw, Tom 1992 December 29 American Health Care: Going Broke in style. The Brokaw Report on NBC Television Network.

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371 Clinton, Hillary Rodham 1994 June 14 Hillary Rodham Clinton Addresses the North Carolina Chamber of Commerce. C SPAN2. Cronkite, Walter 1990 December 15 Borderline Medicine. Frontline on Public Broadcasting Service. Moyers, Bill 1993 February 25 The Healing Mind. Public Broadcasting Service.

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372 APPENDI CES

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373 APPENDIX 1. PATIENT SATISFACTION SURVEY Dear Patient, In order to provide you with the best possible care, we need your help in telling us what you like best about the "Evelyn Perry Community Health Center", and what you feel needs improvement. Please try and answer every question. Feel free to add any comments about our service, staff, and facilities. Important: Please DO NOT write your name on the survey. Thank You. Part one Patient Response Section Please check the appropriate answer(s) 1. This is my __ first, __ second __ third or more visit to EP. 2. I am __ very happy, __ somewhat happy, __ somewhat unhappy, _very unhappy with the services I have received. 3. The doctor was friendly and professional, just professional, __ neither friendly nor pro'fessional. 4. The doctor or nurse practitioner (please check all which apply) : listened to all I had to say --was interested in me (or my child) __ really understood what I was saying __ explained what hejshe was doing answered my questions an adequate amount of time with us did not listen to me --did not seem interested didn't seem to understand what I was saying did not explain what hejshe was doing did not answer my questions did not spend an adequate amount of time with me 5. The medical assistant (please check all which apply): listened to all I had to say -was interested in me (or my child) -really understood what I was saying --explained what shejhe was doing --answered my questions --spent an adequate amount of time with me did not listen to me

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374 APPENDIX 1. (Continued) did not seem interested didn't seem to understand what I was saying did not explain what she/he was doing _did not answer my questions did not spend an adequate amount of.time with me 6. The front office staff {please check all that apply): _was friendly _was helpful seemed concerned for me as a patient was knowledgeable about proper procedures was not friendly was not helpful was not concerned for me as a patient didn't seem to know what to do or how to handle things 7. The services offered are overpriced _fairly priced inexpensive 8. The financial arrangements were explained clearly not clearly not explained 9. The financial arrangements were fair unfair 10. My wait for an appointment was too long _average no wait 11. My wait in the waiting room was under 1/2 hour under 1 hour over 1 hour 12. The social worker was very helpful somewhat helpful not helpful I did not see a social worker 13. overall, the medical care I received was excellent good poor

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375 APPENDIX 1 (Continued) Part Two Patient Demographic Section 14. Please place only ONE CHECK by THE most important feature of a health care clinic. __ its clean appearance ___ courtesy of the staff cost __ the doctors and nurses ability __ my ability to schedule a convenient appointment __ brief wait time in the waiting room Or if you wish, you may fill in your own most important feature of a health care clinic. 15. Check one: I am A. Female B. Male 16. Check one: I prefer being seen by a doctor who is A. the same sex as me B. the opposite sex c. the doctor's sex makes absolutely no difference 17. I am ____ years old. 18. Only if you are 6 0 years old or above, check the most appropriate statement for you ... A doctor on our staff close to my age would; A. Make me more likely to visit the health center B. Make me less likely to visit the health center c. Have no effect on my visiting the health center 19. Check one ... my ethnicity is ... A. African American B. Asian-American c. Caucasian D. Hispanic E. Native-American F. other 20. Check one ... Being seen b y a doctor or nurse practitioner of my ethnic background would make me 21. A. a more comfortable patient B. a less comfortable patient --c. it would make absolutely no difference Check one . My religious A. Protestant__ _ B. Catholic c. Jewish affiliation is . (please add denomination)

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376 APPENDIX 1 (continued) D. other (please add denomination) E. no religious affiliation 22. Check one ... Are you presently employed? A. Yes B. No 23. My job is: ---------------------------------------------24. Check one . My present annual income is approximately ... A. $0-$10,000 B. $10,000-$15,000 c. $15,ooo-$2o;ooo D. $2o,ooo-$25,ooo E $25,000-$30,000 F. $30,000 and above 25. Check one ... my home life situation is best described as: A. being single __ B. living together c. married D. married with a child or children at home E. divorced __ F. partner is deceased 26. Check one ... My highest grade of schooling is ... A. through sixth grade B through ninth grade c finished high school D. some college e. finished college __ f. some graduate school __ g. a Masters degree or higher 27. How did you hear about the "Evelyn Perry" Community Health Center? ---------28. Check one ... Did you used to see a private doctor? A. Yes B. No If yes, for what reason? __________________ ______ __ 29. If you answered YES to question 28, why did you leave your doctor? 30. Check one ... If not a private doctor, who did you visit for your previous medical needs? A. the county health department B. the hospital emergency room c. a hospital clinic D. the Free Clinic E. other-Please Explain:_ 31. Why did you not return t o that facility? 32. What is the reason you came to see us today?

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377 33. Check one ... Upon corning to the "Evelyn Perry" Community Health Center, .did you think our service would be: APPENDIX 1 (continued) A Expensive B. Moderately priced C. Inexpensive 34. Did a particular doctor or health care provider cause you to come to our center? If so, what is the person's name? Why were you attracted? 35. Check one ... Today I saw one of your A. Staff Doctors B. Nurse Practitioners C. Their name was 36. Do you have a habit of annual checkups? Check One: A. Yes B. NO 37. Please explain why you either Do or Do NOT have a habit of annual checkups. Part 3 Social Service Section 38. our "family" at the "Evelyn Perry" Community Health Care Center is thinking of expanding our Social Service functions to better serve your needs and the needs of your family. Please check any TWO ideas which you or your loved ones might use. A. Establish a day care center for children B. Establish a Senior Center which would include a --recreation program, hot lunch program, and daily companionship c. Expand our referral/benefit negotiator staff D. Literacy training E. Lamaze classes F. Neighborhood health fairs G. Neighborhood holiday parties H. Parenting classes I "How to study" classes for high school students J. Talks on how to apply for a job K. Please feel free to add an idea or two of your own .. -------------------------------------------------

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378 1. (Continued) 39. What can we do to improve our services to you? Thank you for your help. "Evelyn Perry" Community Health Center

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Ronald I. Habin, Ph.D. 10419 Manassas Circle Orlando, FL 32821 407-352-8782 (day) 407-292-8265 (eve) Curriculum Vitae Objective: To obtain a position which will allow me to Background utilize my skills as a caring educator, social service client advocate and applied anthropologist. Summary: For the past seven years I have been primarily in training as an applied anthropologist with a gerontology external specialty at the University of South Florida, Tampa. I have been on the department's "cultural trac" and have finished all Ph.D. level academic requirements with a 3.8 Cum .. I will formally be rewarded my doctorate December, 1995. Employment: 1991-Spring 1995 Professor (Adjunct) of Anthropology Valencia Community College-Introduction to Anthropology featured fundamental training in cultural, physical and applied anthropology. 1988-1991 Professor (Adjunct) of Political Science Valencia Community College-Introduction to American Government featured fundamental theories and de facto methods of the workings of this representative democracy at the federal, state, and local levels. Education: Anthropology; Ph. D. The University of South Florida Social science; M .A. Montclair State University Political Science; B.A. The American University Germane Experience Johnnie Ruth Clarke Health Center Inc., St. Petersburg, FL. Design, implement, and for the Executive Director, made recommendations establish critical funding and grant networks, and conducted research in a dynamic urban health care center References enthusiastically available upon request


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