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The Civil Rights Movement, Community Health Centers, and Citizen Participation

As an assistant professor at Tufts University School of Medicine in the 1960s, Dr. Hatch was instrumental in establishing the Mound Bayou, Mississippi, health center (which later became the Delta Health Center) along with Dr. Jack Geiger and Count Gibson. L.C. Dorsey, a colleague and one-time director at the Delta Center, said of Dr. Hatch, “”He is one of the few people I have met in life who is not inhibited in dreaming.”

In this interview, Dr. Hatch explains how the Community Health Center Movement is rooted in the Civil Rights Movement and the War on Poverty, all sharing a common history of fighting for health justice and equity. For health centers, that fight began with a vision that ultimately transformed healthcare over the course of more than 50 years.

It started with reaching beyond the walls of the traditional exam room to break the cycle of poverty and illness and address the social drivers of health, attending to patients’ nutrition, housing, and sanitation needs. A case in point is Dr. Hatch’s vision to create the North Bolivar Farm Cooperative:

“We manufactured outhouses and put screens on windows and brought in new concepts of eating and what was healthy.”

Dr. John Hatch discussing the Mound Bayou health center

Dr. Hatch recognized citizen participation as key to empowering communities and finding solutions to health needs. As he puts it: “What say would people have in the structure and organization of the health care system?” He also calls for activism and policy change to address the challenges facing the health center movement today.

The result was a health center that historian Thomas J. Ward described as challenging “the racial, social, and class systems of Mississippi with its mission to empower the poor and dispossessed through community engagement.”

Additional reading about Dr. Hatch and the Delta health center

Out in the Rural: A Mississippi Health Center and Its War on Poverty

NACHC Blog: The Life of Dr. John Hatch

The First Community Health Center in Mississippi: Communities Empowering Themselves, Dr. Jack Geiger

Leading the Charge (Tufts University)

Interview transcript

Transcript

Ben Money: Hello and welcome to health centers on the front lines, the podcasts of the National Association of Community Health Centers. We have a very special episode for you today, and I’m excited for you to hear it. I’m Ben Money, NACHC Senior Vice President for Public Health Priorities. And joining us today is professor emeritus of public health at the University of North Carolina, Chapel Hill, and a legend in the health center movement, Dr. John Hatch. Dr. Hatch was instrumental in establishing one of the nation’s first community health centers in Mound Bayou, Mississippi, which at the time was an all African American town where he pioneered approaches to addressing social drivers of health. Dr. Hatch went on to become a national, nationally known public health leader and pillar of our movement. Welcome, Dr. Hatch.

Dr. Hatch: Thank you.

Ben Money: Several years ago, at one of the early Faith and Health lectures named in your honor I was speaking on the topic of health center screening for social determinants of health. Always my teacher in public health, Professor, you kindly corrected my terminology, stating that these were drivers, not determinants. The field is now moving away from the term determinants and now calling them social drivers or even structural drivers of health. Why do these terms matter?

Dr. Hatch: I think they welcome a different level of conversation. That expectations within professions have moved forward at a pace that enables communities to play roles that really weren’t believed possible by many people 50 years ago.

Ben Money: Tell us about when you helped to organize the Mound Bayou, Mississippi, community to establish the first health center.

Dr. Hatch: It wasn’t the first Ben. It was a second.

Ben Money: The second. Okay. Okay. I know that that’s a little bit of a debate that goes back and forth. So thank you so much for clarifying that. Now the record is set that it was the second community health center. What were those social drivers of help that you identified and how did you address them?

Dr. Hatch: Well. At Tufts University, the two people who most enabled the effort at Columbia Point — a public housing project where the first center was– brought together anthropologists, sociologists, people from the community. So the conversation sort of started at a different level.

One thing I would like to interject here is that Jack Geiger had been preparing, I guess, four or five years, with the hope that he would be able to practice community health at a global level. And he was thinking about health care in Africa and other less developed nations. At the same time, the Civil Rights Movement was attracting a lot of young people from the North, especially to participate with Black people and to call for freedom.

And Jack Geiger, Count Gibson, the physicians from up north, volunteered to go South to just sort of evaluate what’s going on with these young people. And some were in distress and some were beaten. Some were killed. Black and white together.

It was the first time we’d seen anything like that in the South, excluding perhaps a civil war that was not all successful in bringing about the pattern of justice that many Black people had hoped for. But I guess overall, where Jack Geiger or Count Gibson was coming from was to begin to place the United States among the nations suffering great disparity in health status.

And what should we hope for? Well, at that time, the nation was saying we should give everybody a checkbook to go to see the doctor. Well, these men were at a point where it was like, no, it’s not just money. It’s also: What say would people have in the structure and organization of the health care system? Would they respond to issues that we see as important?

Out of that grew the notion that citizen participation should be a part of, not only the health movement, but the entire, what we called at that time, War Against Poverty. I guess it was the Johnson administration. So we started in Boston. And my job was to sort of coordinate the survey process in several southern states because we didn’t know exactly where it would be possible.

There were political issues. And a reaction from physicians in Mississippi, both black and white, saying that is going to cut our practice. Black people welcomed the service. But Black doctors said, But how we going to eat? It’s already not much out there.

So those were kind of the realities as we began the process. And certainly Dorothy Farebee and Matthew Walker of MeHarry [Meharry Medical College] were vastly influential in helping us to think about what a health care team in Mississippi might look like, who they could talk to.

There was a lot of radical rhetoric around citizen participation, but nobody quite knew what that meant: Are we really going to let people can’t read and write sit up and make decisions about health care? Eventually, the answer was: Yes. And we put together over time and with mistakes, groups of people who certainly enhanced the targeting and appropriateness of things that we did.

Another way to look at it, it was very closely akin to theories I read about an economic development process where tasks were viewed from the perspective of what part of this could we develop local talent? How much education do you really need to be a nursing assistant? How could we get professional organizations and societies to respect the new kinds of professionals that we propose to develop?

Community outreach workers, nursing assistants, community health workers. Part of my job also was to discuss options and perspectives. Hopes and dreams. And encourage local people to participate because initially, you know, the response was, Are you crazy? Are you going to really turn this over to, you know, a group of people who might struggle with language and expression? You know, and they would really do important things? Of course, the answer was yes.

And there were talented people who. Some of whom were not literate. Anita [Dr. Hatch’s colleague] and I were discussing a man in environmental engineering. I think we also were the first health center to have an environmental engineer– who incidentally trained about 25 environmental engineers in Mississippi with the help of Tufts University, University of Cincinnati, Dayton, and other established training grounds for sanitations. The Sanitary Society approved the program. The people who became engineers had to spend six months/ a year in one of the schools that were co-sponsors of the environmental engineering. But it had a profound effect on the community.

Yes, we manufactured outhouses and put screens on windows and brought in new concepts of eating and what was healthy. So we were really trying to — I think rather well — the opportunities that would be possible in the community health center movement. Some people went on to become more technically able, some became licensed technicians and so forth. But the real story is in the hopes and dreams of their children and grandchildren.

Ben Money: What were the things that you saw in your assessment of the community that indicated to you that the health center really needed to move in the area of environmental health and focus on things that were outside of the clinic setting rather than simply treating patients?

Dr. Hatch: Indeed. I guess it’s fair to say among the highest infant mortality rates in the nation will be found in the Mississippi Delta, which was the location of many large plantations occupied by people who had not been able to make it north yet. But the process was going.

So we had a lot of elderly people for the first time living alone. Prior to the decline in cotton production, Black people were very welcome. But as that began to happen, the pace of migration increased. And often people with very little preparation for urban living found themselves in Boston, New York, Chicago, Detroit. (Including some of my relatives, I might say).

But the conditions were as dire as they were likely to be in this country. Shacks. Poor sanitation. Insufficient amounts of food. Low levels of education. And not a whole lot of hope in the poor community. When we arrived and on site in Mississippi in 1965 or so, the average income of a very competent cook housecleaner was $15 a week. And those who are employed consider themselves fortunate. These were counties with predominant Black population.

Ben Money: I wanted to pick up on what you were just talking about in terms of just the abject poverty that that you saw in that service area. There was widespread malnutrition in that region. And you initiated and directed the North Bolivar County Farm Cooperative to serve as kind of an adjunct of the Delta Health Center. Do you feel like that was the right approach?

Dr. Hatch: Yes.

Ben Money: Feel like that was the right approach?

Dr. Hatch: Yes. It had been. Well, what started some of this process also? O’Neill had called Geiger to account. When he sent in a big bill for staples, me, bread, canned goods, etc. said, What’s going on? It looks like you’re running a chain store on the government. And Geiger said, Well, if people are hungry, the specific [remedy] medically is to feed them. And they were tolerant. They were good people. But, you know, nobody had ever passed out groceries or the health facility, to our knowledge. But I’m sure it had happened before.

Ben Money: Well, you know, in many states right now with Medicaid programs, including North Carolina, there’s provisions in place to allow Medicaid dollars to actually cover non-medical related things like food and housing supports and transportation that impact the person’s ability to to maintain their health. And in fact, we’re supporting health centers that doing more than just screening for social drivers of health.

Dr. Hatch: I sure hope so, because, you know, in rural Mississippi. It was common for shacks not to be generating much rent, you know, like rent is $4 dollars a month or maybe less. At the same time, there was very little maintenance once the owners didn’t have a vested economic interest. So steps were missing from a shack where pregnant women lived — that didn’t make a lot of things or because there were injuries just as there were mosquitoes. So putting windows, screen windows to the shacks. Might look like. What are you doing? But it very well could preserve the life of a mother and child.

And I think the health center probably did go mostly toward mothers and children and health of the family. And I think perhaps rightly so. But the needs of elderly people were sometimes alarming because families had sustained life in whatever way they had to, including fishing. Hunting. And even hunting, which was a staple when I was living in the country. You know, we’re in the hunt just for fun. We hunted for meat. We hunted for nuts and vegetables. And the same was true in rural Mississippi, especially when you cross over the levee and go in the land closer to the water.

There were berries, nuts, fruits. Most people my age knew how to go around and collect edible things that grow. Oh, dandelions, flower leaves, so forth. I learned that from a grandmother who had been born in 1852 and had lived through the slave experience. Most people my age — right now is 94 — have had those kinds of experiences with people whose journey has not always been secure.

Ben Money: And when you were developing the North Bolivar Community Farm Cooperative and really thinking about those efforts at addressing social drivers of health, you know, 50 years ago it did could you have envisioned what health centers could become? Is this what you had in mind? Because right now we’ve got health centers that are established in grocery stores, farm co-ops, transportation systems and even affordable housing projects in Denver, Colorado. And there’s a health service building, 150 units of affordable housing on top of their new facility.

Dr. Hatch: Well, Ben, you know, this first time I’ve heard this and I’m just overjoyed that is going on. But yes, indeed. My concern was that bringing in truckloads of food from Minnesota and Illinois to people who had spent a lifetime growing stuff was kind of insulting. What they lacked was the money to plant and land to plant it in, they had the know-how.

Certainly, African American people in the rural South had survival skills to hope to prosper. By November, my family had enough food to eat for the next two years in the shed behind the house. Urban situation is different. But ingenuity there as well at Columbia Point was. The Public housing unit, the first health center. And there were women at Columbia Point who went to the big market in Boston, bought food, canned it, and put it under the bed.

 Ben Money: Yeah. That that ingenuity of people is is amazing. And one of the things that we’re seeing now is you talked about sort of the decline in natural areas in the south and access to places where you can hunt and find fish. You know, so much of that has been impacted by environmental degradation that has occurred in communities of color. The poor have historically been relegated to live in redlined districts that have been now termed as sacrifice zones where toxic waste dumps, polluting highways, chemical plants, emitting air and water pollution are cited. The health impacts of these conditions are profound from lead contaminated water, creating developmental delays in children to cancer and respiratory conditions. You’d mentioned the Environmental Health Engineers that you had at Mount Bayou. How do you think that legacy could be continued today, given all the challenges that health and patients in their communities are experiencing?

Dr. Hatch: Okay, first, we know there’s got to be a political process. Communities in most cities or they have interstate highways, are located in minority communities. And Boston. The path for airplanes leaving Logan Airport were over the predominantly black part of Boston. It is deliberate planning. More sophisticated people can anticipate and make scientific input into a process that will lead to change.

It also enables me to mention the name of an old friend, Ted Parish. I think you knew Ted. Parish was a youth worker, community organizer in the south end of Boston. And some interests had seen fit to revitalize the South End and turn it into the most elegant community in the city. The housing design was lovely. Well done. The houses were still stable after 150 years and all you needed were people with money to come in and really add tone to the presence.

And thenTed Parish started sit-ins took over a number of houses and the city had a crisis on its hand with several hundred people arrested. He continued this process until there was negotiation that enable the creation of 100-odd apartment units that would be available to people of modest income.

It’s disruptive. It’s dangerous. And sometimes heartbreaking to observe the confrontation between police who were simply enforcers. And people who see their future disappearing. But in Boston, I think they dealt with it eventually in a fairly effective manner. Ted received the next year the Outstanding Social Worker Award in that city. You know, there was conflict, people were jailed and in other locations I could imagine them being shut down for impeding the economic development of the city would be one way to describe it.

Ben Money: I mean, one of the things that you point out is the fact that change doesn’t happen without some measure of conflict. And I think that’s really important. And, you know, one of the things that we’ve seen is that after the murder of George Floyd and the disproportionate deaths in black and brown communities due to COVID 19, much has been made about addressing justice, equity, diversity and inclusion. Almost every health care organization has issued a statement. They’ve created internal DEI teams, have hired a chief diversity officer. You know, I question whether some of these actions are just performative without any real and lasting impact. How would you advise health centers enact to make real and substantive changes to in racial equity?

Dr. Hatch: And what they did also was to bring in social science and statistics as a part of measuring impact of the health care intervention. And I think now not many people would advocate just giving, putting more dollars in the pocket alone as an appropriate health care intervention.

I think we’ve learned from those experiences, realizing that just paying the doctor won’t do it because it won’t change the poor housing or the political climate of the community. And I think so far we haven’t found a substitute to participation.

And, you know, all throughout this movement and people from the community have made a difference. In China, they were village elders. They were not educated people. Same thing in Mississippi.

Now the older folk went to school to qualify for the jobs available at that time. The children have gone further. When we went to Mississippi, I think there were fewer than 20 black physicians in the whole state. Now through the Delta Health Center, and its knowledge of pathways and the recruiting that went on to other medical schools will.

Tufts University did some things that would be controversial today like, recruiting a science major who’s teaching in Mississippi to go to medical school and give them two years – no four years — to do the first two under normal tutelage. Now that’s politically very sticky and difficult. But they did it. So there is a record of people who finished Mississippi’s schools. Were allowed for years to get through the first two and then they could fly. And it resulted in a profound change in the pool of African-American people from Mississippi who were able to get medical, nursing, environmental training.

Some of it storybook stuff. Like the gentleman who was Chairman of the board at Mound Bayou when I was last there. Had completed his career in California, said he had finished his master’s and environmental engineering and then got to APHA (American Public Health Association conference).  And the director of a health center in California says, hey, we could use an environmental engineer, would you consider it? He said he really didn’t consider it, but the guy offered him a ticket to fly from Mississippi to California for two weeks to look around. And he took it. And they said, then they offered me more money than I ever thought I’d make in my life. So I left Mississippi. Well, there are a number of stories like that were. Maybe they didn’t go back, but they entered a new world with the sensitivity that many people who had not seen poverty would not recognize.

Ben Money: It is that lived experience, you know, in addition to the sensitivity, really helps inform the projects and the initiatives they undertake and their ability to rate relate with the communities they serve.

Dr. Hatch: Yeah, well, I think the Community Health Center has probably enabled more African-American, Hispanic, ther poor populations, including Appalachia, to reach levels of employment that was traditionally out of reach. Some programs were modified and then there was an analysis of abilities to perform.

One of the more unique cases was a man in Mississippi who was not literate. But it was one of the brightest people I’ve ever met. The Master’s degree trained director of engineering, environmental engineering at Mississippi was a guy named Andy James. And and they hired this guy because they’re quick minded and willing worker and all that. And one day. And it was trying to put together some kind of machine. This guy walked in and say, What’s that? And he said, Well, you know, it’s hard to put in. You have put this thing together driving me nuts. This illiterate man picked it up and said, Well, I think this goes here and that goes there. And he followed the diagram and put the thing together. And the director of the program was dumbfounded. You know, this man is not literate, but he put the thing together. And he went on to become a part of the research team testing wells, knowing how to go and adjust the microscope. Oh, that look like clean water drawn from a local well open and all the stuff crawling in it. And he said, bacteria don’t those germs. And I remember seeing 50 people standing in line to look through a microscope in Mississippi. And marveling. At this thing they could look at clear water and find bugs in it.

That was a profound experience for me. And I wonder to this day if one of us who had college education had been conducting the education session, would people have gotten the message? I don’t know. But they kind of knew that Nelson was smart, but he couldn’t read and write. Because his folks had prioritized, you know, picking cotton.

Ben Money: He had to just to survive. And he didn’t have the benefit of a foundational education. But yet he was a very intelligent and capable man. Yeah. You know, so what what I hear you saying is in terms of health equity or equity, racial equity, health centers kind of have two approaches. They’ve got the approach of the work we do out in our communities to address particularly health disparities. But then the work we do inside our health center to grow our own, develop our own staff and invest in the people that work with us.

But I’ll tell you, community health workers are impressive in their own right. I’ll tell you with the COVID pandemic. And when I was in public health, we couldn’t have made the kind of headway we did in terms of getting our personal protective equipment and health messaging, getting folks tested and eventually vaccinated. Without the community health workers.

And I’ll never forget the time that I joined you. It was probably back in 19 is going to be 89 or 1990. We went to St Helens Island to the Penn School for a North and South Carolina lay health advisor training that that you facilitated. That was one of the most memorable and impactful experiences that I’ve had in my public health career. And I just want to, again, thank you for that that opportunity you provided to me, gosh, over 30 years ago.

Dr. Hatch: Yeah, well, you know that one of my favorite places I served on the board at Penn Center for some years. And it was a joy for me to interact with the people, as, you know, most of them. Or direct descendants of a West African population who came to America to grow rice. And they had stayed around the Hilton near that area from the time of slavery up until the present time and had worked out an agreement with the slave owners that they wouldn’t try to run away if the slave owners allow them to practice their faith and their family traditions. Africans tended to believe that distance and relationship for marriage was what you tried to encourage and the settlers were slave holders believe that close marriage to protect the money might be the way to go.

But there coexisted under some tension what has been described as an independent black or African cultural system coexisting with the slave society in the South. And, I’ve had the great pleasure of having African students for summer programs or Chapel Hill. When it’s possible. I’ll try to help them to find predominantly African communities in this country. And, you know, that have survived sometimes two or 300 years of exposure to slavery, but still maintain pieces of language and lots of the practices brought over from Africa and there’s been a lot of work by anthropologists and others in the ways that these populations have interacted and what’s left of the African tradition. Yeah, I, I guess I was involved on the board for maybe 15 years.

Ben Money: Very much so I actually am in touch with the new CEO of the Beaufort Jasper Comprehensive Health Center in in that area. And she sent me some archival footage from the local PBS channel on the well drilling that they did back in the in the late seventies. Because, as you know, the pediatricians at that health center would see a lot of children that had intestinal worms and they treat the worms. And children would come back and they treat the worms and over and over. And then they realized that it was water. They did water testing, found that the wells were mixing with the the septic systems, the yeah. Septic systems and they needed to drill wells lower. There wasn’t that capability within the county or a willingness to make that capability for those poor, poor black communities. So the health center actually but well drilling equipment and drilled those wells and addressed the issue of intestinal worms.

Dr. Hatch: Yeah. And we did the same thing in rural Mississippi, drilled wells, built outhouses and taught people in community how to do those things.

Ben Money: Yeah. And, you know, it’s the challenges in many respects that health centers see today are are similar, but yet they’re different. And I think in many instances, they’re they’re even more complex. But it really is through your foundational work and health centers, living out that legacy and seeing their services beyond just the four walls of of clinical care and and extending out into the community that that health centers are really making that that difference and sit in that space between public health and primary medical care.

Dr. Hatch: So I’d like to ask you a question.

Ben Money: Yes, sir.

Dr. Hatch: I think rural populations in the south found strength and structure, and as you know, a lot of the work I’ve done in North Carolina was focused on churches, as was the case in Mississippi. And. With urbanization, it’s less clear to me that the traditional cultural systems that have enabled cooperation in the rural South or in southern cities exist in northern communities, for example, like Boston, which in 1925 held about 7,000 Black people, period. Now, with a black population of a quarter of a million. Mixed population, West Indian. Canadian black. Hispanic. Do you see entry points for development of, through prior institutional development, I guess would be my question?

Ben Money: But yeah, I do. But I think it’s it’s even more varied now because now you have the advent of these virtual communities, these online communities, which for a lot of younger people have the same sense of community as do some of the physical, social and societal groups that have traditionally been in place, groups like the fraternities and sororities, social club, bowling clubs, even. You know, you see less of that and more variety in modes of gathering than you have in the past. I even see that that has changed as a result of the pandemic, that during the pandemic, out of necessity, there were a lot of churches that went from face to face to virtual.

And now coming out of the pandemic and, you know, we’re still in this wave. Churches have gone back to face to face, but then they’re also doing virtual. So I know, for example, with my church, we have people that joined that at one point had lived, you know, in North Carolina, but are now living in other parts of the country. But because they have a virtual service, they join in. But it’s a different it’s a different type of engagement when you’re joining online and when you are face to face and in person. And I think one of the questions is yet to be determined is what’s the level of community cohesion in a sense of mutual concern and accountability that will see when these virtual communities become more and more.

Dr. Hatch: Yeah. It’s a challenge. And. I recognize the continuing, continuing change in the decline of rural population and a struggle for adaptation. I see it in my own family. Certainly, for my family, it was the church that was the place to go to prepare for change and upward mobility. It was a place in North Carolina where Southern blacks and white groups like the Quakers could come together and and do things. I’m just less aware of the turbulence in this present environment. I think the nation is going through a period of reassessment – it is sort of disorienting to me.

Ben Money: To me as well. To me as well; it’s actually fairly frightening.

Ben Money: You know those institutions in rural areas and urban areas that have been the glue, are they still that fabric of our society? And one of the things that we want to assure at NACHC is that, you know, community health centers will be there to be those foundational patient governance community institutions that can help to achieve health equity and social mobility for the people that we serve.

So Dr. Hatch, I just want to thank you so much for the opportunity did it to sit down and chat with you. I miss that we’re not face to face. I look forward to seeing you in December in Winston-Salem, but I just want to say thank you, thank you for your leadership. Thank you for your wisdom and guidance and your you’re just sense of the arc of history and how this movement has really been tied to the civil rights movement. And you just always have, have, have a clear and present sense of where we need to go and what we need to do.

So thank you, Dr. Hatch, for your time.

Dr. Hatch: Thank you so much.

Produced by Heartcast media.