I think my experience with the War on Poverty has been one of the most gratifying of my life. As doctors, you all know that satisfaction of making a creative diagnosis of unfamiliar symptoms--devising a completely new treatment--and effecting a cure.
We have not yet cured poverty in this country, I am sorry to say. But we have identified the syndrome of poverty---we have developed that work-- and we know that time and money-- that joint therapy of nature and man-- will ultimately end poverty in America.
Four or five years ago-- no one could have stood before you and made that confident prognosis.
The disease of poverty had not yet been isolated. It masqueraded under many different names. Its symptoms were misunderstood and unrecognized. No one would have been able to specify a treatment even if the disease had been diagnosed.
Today, we know what poverty in America is. We believe we know what to do about it. And for the past two and a half years we have made a national, local and personal commitment that surpasses any peacetime effort in our nation’s history.
What is poverty? We used to think it was just being without money. And so we had various charities -- that provided clothing for unfortunate children -- odd jobs for the unemployed man -- and a Christmas turkey to maintain the pauper’s faith in the goodness of the rich.
Today, we know that poverty is far more complex than the mere absence of money. And is far more widespread than we once believed.
By our rather conservative definition of a maximum per capita income of $750 per year, 32 million Americans are poor. 70% of these are white. 45% live-in rural areas. 40% are children. 25% are old.
Today, we know that if we guaranteed a marginal income for a full year to every poor American, at the end of that year, almost none would have gotten out of poverty.
This is because poverty is not just being without money. It is a lack of education. It is not having a marketable job skill. It is not having access to a lawyer or a doctor. It is living in the darkness of an urban slum. It is being a child in the ghetto. It is being a Mexican-American along the Rio Grande. An American Indian on a Navajo reservation. An American Negro in Hough or Harlem.
The welfare check is not a one-way ticket out of poverty. It is just a claim check on a subsistence life. It may buy enough food, or rent, or clothing to keep alive and decent. But it doesn’t buy skills, motivation, or hope.
The anti-poverty programs we have designed to combat this complex disease are like the time capsules which some of you prescribe for colds. Maybe some of you even take them. I know they impress me on the television commercials.
You know what I mean. You swallow a big pill and inside it has hundreds of little pills which dissolve at different rates of speed-- and, so, keep acting over a long period of time.
Head Start, for example, is just such a delayed-action capsule. While the big part of it dis6olves quickly, giving the pre-school child a tremendous boost into first grade, its other vital ingredients release their benefits over many years.
Medical examinations make for better health in adolescence and adulthood.
Family counseling and parent participation create a happier home life and environment for years to come.
Motivation for learning may not fully unfold until high school where instead of becoming a dropout, the Head Start child sets his sights towards higher education.
Job Corps, another of our programs—and a very controversial one-- has a long-range economic, psychological and social payoff that extends over a life time. Its immediate impact is the teaching of literacy and job skills for present employment. But, in addition, it instills motivation and self-pride that lasts throughout a career. And it creates social responsibility that comes into its own in mature citizenship.
The most complex and creative of our remedies are those which come under the heading of Community Action. On the surface, this is an idea which seems deceptively simple-- even trite. The kind of thing you, think you know all about because it’s been around all the time. Like mold,- which no one, until Alexander Flemming, perceived as penicillin.
Community Action seems like an American tradition we’ve always enjoyed, like the New England town meeting-- or the citizens school board-- or the secret ballot.
But in our time, and in our terms, Community Action is very new. It is the harnessing of local talents and energies to a unified attack on hometown poverty with the aid of federal funds.
What is new about it is that everyone in the community can have a piece of the action. Not just social workers. Not just educators. Not just do-gooders. But businessmen, clergymen, doctors and, of course, the poor themselves.
Community Action is not a rigid social welfare structure imposed by some remote bureaucracy. It is rather an organic creation of the neighborhood itself. Molding itself to fit the unique and diverse needs of each of more than a thousand different American communities.
Here in Cleveland, for example, Community Action ranges from Head Start programs to a non-profit corporation called HOPE, whose purpose is to improve slum housing and train citizens in home repair. There is a Legal Services program, with lawyers working out of seven neighborhood offices. Its advisory boards consist of the Legal Aid Society and a special committee representing Cleveland’s Bar Associations and the John Harlan Law Club.
There is a community information service, five neighborhood opportunity centers, outreach workers to go from door to door counseling, and giving information.
A Foster Grandparents program, run by Catholic Charities Bureau in which elderly poor people work with institutionalized children, and other job training, consumer education and general education programs.
This is Community Action in Cleveland. In other place, it is something quite different. In six communities, it includes health centers.
Why a neighborhood Health Center? Because that is what the people of the community thought they needed more than anything else to help them out of poverty. No Washington bureaucrat told them they would have to swallow the center. The people themselves -- the poor people and the representatives of all segments of the community recognized that among all the other needs -- for jobs, for housing, for better schools -- bad health and inadequate medical facilities were undermining their capacity to possess the rest.
I am sure I don’t have to rehearse for you the grim statistics of the health gap that exists between the poor and all other groups in our society.
- you know that one-half of all women who have their babies in public hospitals have received no pre-natal care at all.
- you know that 60% of poor children receive no medical care, never see a dentist.
- you know that adults in poor families have several times more disabling heart disease, arthritis, or mental illness than in families that are not poor.
- you know that the chance of a child dying before the age of one is 50% higher for the poor. And the chance of dying before reaching the age of 35 is four times greater for the poor.
It stands to reason that poor diet -- illiteracy, unsanitary living conditions, filth and rodents, absence of regular or pre-natal care -- all go towards the compounding of a poverty and health disaster.
One of the things we learned when we began this national attack on poverty was that the poor are much poorer than we had ever dreamed.
When we started the Job Corps we were shocked to learn that 80% of these teen-age boys and girls had not seen a doctor or a dentist in the past five years. They were 15 pounds underweight on the average.
Their teeth were bad.
In Head Start, we found that-
- 70% of these 4 and 5-year-old children had never had a Medical or dental examination.
- 45% had cavities.
- 60% received measles vaccinations for the first time through Head Start.
- 32% had never had a smallpox vaccination.
Through the simple Head Start medical examination, physicians found:
- 98,000 children with eye defects and helped them get treatment.
- 90,000 with bone and joint disorders and treated them,
- 7,400 were discovered to be mentally retarded and referred for special handling.
- 2,200 active cases of tuberculosis were discovered and treated
These are the facts. They are particularly poignant when we consider the high quality of medical care available to most Americans. They will not go away, as long as those in poverty are denied access to this care. As long as there are slums with no exits. As long as the nearest general hospital is 12 miles from Watts-- a two-hour bus ride with two changes, or, a $3.00 taxi fare from Columbia Point in Boston, after public transportation shuts down at dusk.
It is no wonder then that the people of scores of communities are asking for health services as a major ingredient in their Community Action programs. Increasingly, they are finding allies in local medical societies, medical schools, health departments and hospitals.
This denial of health services is not the fault of the doctor-- not the fault of the hospitals-- not the fault of the medical schools. They have all done a magnificent job of creating the technology, the arts and sciences of healing by which disease may be cured. The trouble lies in a national failure to develop adequate delivery systems to bring this skill and care into the forgotten regions where they are needed most.
And this is not just true of medicine. It is true of education in the urban ghettos and -remote reaches of rural America. It is true of justice. It is true of job opportunity. It is true of communication. In the War on Poverty we and the communities are trying to build these delivery systems.
When the people of New York, or Chicago, or Boston, or Denver, or Mississippi, or Watts, or Cleveland ask for Community Action health services, they are seeking what LGOK Magazine in a recent article called “typically American democratic medicine” -- a way which has been encouraged and supported by your own national American Medical Association President, Dr. Charles Hudson.
As of now, neighborhood health centers are part of community action in six cities. By July 1st, we hope to approve grants to 24 or 25 more. These projects are not necessarily where we want them. Not how we want them, But where and how the communities themselves want them.
Everyone of you knows how important a good bedside manner is to successful treatment. It is certainly no substitute for skill, but an adjunct to it. A personal rapport which puts a patient at ease and makes his cooperation automatic.
“Where does it hurt?” The doctor asks. “Here,” the patient says. If he is afraid, he may be lying. If he is distrustful, he may answer, “It doesn’t hurt at all.” And hide his suffering with silence. Another patient says, “Here” and means it. When he helps through his description of symptoms to make diagnosis easier-- that is community action on a one-to-one basis. That is the real meaning of the patient-doctor relationship.
We asked Watts, “Where does it hurt?” The people there told us. The University of Southern California Medical School told us. The businessmen and politicians told us. “Our health hurts,” they said, “and we are too poor, too isolated, too far off the beaten track to do anything about it.” And so, we and they are building a health center in Watts.
We asked the people of the Lower East Side in New York, “Where does it hurt?” And they, too, answered. “Our health hurts.” For the last eighteen months, the OEO has helped Beth Israel Hospital which operated the Gouvernous Ambulatory Clinic to expand its services to the poor. The results have been astonishing. The clinic has served 60,000 individuals who have made more than 200,000 visits. 97% of the pregnant women in the area have come to the clinic for pre-natal care. We asked Mrs. Jane Bradshaw of Pueblo, Colorado, “Where does it hurt?” She told us what poverty means to her. She said:
“Poverty is taking your children to the hospital and spending the whole day waiting with no one even taking your name. And then coming back the next day-- and the next-- and the next until they finally get around to you. Poverty is having a child with eye trouble and watching it grow worse-- everyday—while the welfare officials send you to the private agencies and the private agencies send you back to welfare-- and then when you ask the welfare officials to refer you to the special hospital, they say they can’t. And then when you say it is prejudice because you are a Negro, they deny it flatly--and they shout at you: ‘Name one white child we have referred there'- and when you name 25, they sit down- and shut up-- and they finally refer you, but it is too late then because your child has permanently lost 80 percent of his vision- and you are told that if only they had caught it a month earlier, when you first made inquiry about the film over his eyes, they could have preserved his vision.”
The gravity of our failure to deliver adequate health services to the poor becomes even more serious when we realize how many individual physicians, surgeons, nurses and medical technicians have given of their time and skills ‘beyond the call of duty and at no cost to help the poor.
But unfortunately, a morning or afternoon in the clinic is not enough when the patient has to lose a day’s work-- a day’s pay to get there.
The most skilled treatment is not enough when the patient has been sitting on a corridor bench for four hours waiting for those healing hands to extend to him.
The most able diagnosis is not enough when it is the rest of the family back home-- back in the slum-- which is even sicker than the patient who made it to the clinic. And consistent care, careful diagnosis, are impossible when services are fragmented-- miles apart. The cataract goes one place-- the weak heart travels to another. The arthritic hand to still a third--. Somewhere, between these isolated waiting rooms, the human beings who owns this grief, silently slips away.
The Neighborhood Health Center puts the pieces together in one place and that place is the neighborhood where the people are. To the skill of the physician, the health center adds the catalyst of community action.
Ask the community where it helps and they will tell you.
We set no requirement as to hours in our health center guidelines. The people of the neighborhood councils, members of the board and the staff make this operational decision among themselves. The result: everyone of the OEO Funded Neighborhood Health Centers is open nights and weekends. That’s when it’s easiest for the people to come and that’s when the doors stay open for them. At the Gouverneur Clinic, the ratio of emergency room visits to regular treatment has dropped drastically because the regular clinic is available when the people can get there.
When the Columbia Point Center in Boston was being designed, the doctors from Tufts Medical School consulted with the neighborhood people about furniture and equipment. They said that in the pediatrics clinic there would be cribs in the waiting rooms for the sick children to rest until the doctor was ready for them.
“Uh, Uh,” said the neighborhood mothers. “Sick children, fearful children want to be held and the mothers want to hold them.”
So, rocking chairs were put in instead of cribs. And parents and children are happy instead of frustrated and afraid.
The health center serving the east side of New York has Chinatown in its area, but very few of its patients were Chinese. They didn’t come because they were never sick, or not poor. But because of pride, timidity, and the language and culture barrier. The neighborhood people came up with a solution and now a resident of the community, named Suni Wong, serves as Chinese health educator, and with him on board, a whole new area of delivery of services has opened up.
While there is nothing quite so personal-- quite so private as the relationship between patient and physician, I think there is a close and meaningful analogy between health services for the poor and what we have learned from our well-established program of legal services for the poor.
As with health, our nation has the most comprehensive system of jurisprudence in the world. But as we began to explore the symptoms of poverty, we found that here, too, the delivery system has broken down.
We discovered that the poor generally regard the law as an enemy-not a friend. And justice as a stranger not a neighbor. The reason for this is quite simple. The Supreme Court is emblazoned with the words, “Equal Justice to all Under Law,” but you can search the ghetto and never find these words. To the poor, the law means surveillance, at best. Trouble at worst. And, too often, justice is meted out to the creditor, the landlord, the administrative agencies, the vendors, the finance companies, while the poor man cannot find a single friend in court.
With the support and cooperation of the Bar Associations of America the law schools, and the law enforcement agencies, we devised a new concept of delivery of justice for the poor.
Today, more than 1200 full-time lawyers represent the poor in civil actions, working from store fronts, mobile offices, even circuit riding in remote rural areas.
They are winning 75 percent of their cases-- while before the record would have been zero. They are working on new laws, setting new precedents, challenging old concepts, changing the curriculum of law schools, and the training of young lawyers.
Above all, they are proving to millions of Americans that justice is a friend. Today, figuratively at least, those noble words “Equal Justice Under Law” are to be found in hundreds of places where they were never seen before.
If injustice keeps the poor poor, bad health is seven more debilitating. Neighborhood health centers-- soon to be 30 or more-- have the words “Equal Health Under Care” engraved figuratively over their doors.
To the patients in these centers, treatment is no longer to be feared. The doctor is not a vague shadow figure at the end of a long corridor, at the end of a long wait, at the end of a long bus ride, at the end of a long payless day. He is part of the community, part of the action that is helping millions of Americans on their first steps up the ladder out of poverty.
A week or so ago, Dr, Joseph English, the Deputy Director of our health programs, and that Peace Corps psychiatrist I told you about, sat in on a meeting of the neighborhood council at Watts where the new center is under construction. Being a psychiatrist, Joe had considerable anxiety about how things would go. “The administrators sat around the perimeter of the room. Neighborhood people sat in a circle of chairs, the chairman of the council-- a middle-aged Negro woman, a resident of Watts for 15 years, began the meeting with a prayer. Then she asked the group to pledge allegiance to the flag. This was done. Each member of the group rose and introduced himself and the professionals were asked to do the same. Dr. English’s anxiety soon disappeared. He knew that the people felt they belonged. They were part of the medical team. Here’s what he said to me when he came back:
“I couldn’t help but think that if part of the problem of the people of Watts is little sense of their self-worth and identity-- then, no group of sociologists or psychologists could have worked out a process better geared to overcome such a problem. Each council member introduced himself and told, with confidence and pride, why he had been chosen to serve.”
As one man put it-- “The new center is growing out there-- but it’s growing inside us, too.”
Remember, this was in Watts-- a disaster area only two years ago. Still a wasteland of little opportunity and little hope. But, because of the neighborhood health center, these people feel that they have both hope and opportunity. A great feeling has come to Watts, but an even greater feeling has come from Watts-- not only are the local residents planning with the professional staff for the opening of the facility, but once it is opened, they will help in its operation.
Now they feel that it belongs to them, not to the Federal government, not to the state or the county, not to the city, but to them. And, they are looking forward to the time when their sons and daughters will pursue health careers in the Neighborhood Center they have helped create.
I am not a doctor, but in both the Peace Corps and the War on Poverty, I have learned to tell the difference between sick people and well people, sick societies and healthy societies.
I can tell you there is no greater or more satisfying role that physicians can play than to join in community action to help create a healthier city and healthier citizens.
The poor need to know that doctors are as much a part of the effort to help them help themselves as educators, businessmen, lawyers and clergymen-- all of whom have been deeply involved in the War on Poverty.
Here in Cleveland theta is a tremendous need for your support and cooperation. Dr. Hudson has put it extremely well.
“A local program will continue the effective inter-action between medicine and government because no such program can be carried out without the cooperation of every element of society that is interested in health care, whether the elements be public or private. Governmental agencies, public or private. Governmental agencies, public health officials, other governmental personnel--all Play key roles in the local program along with their colleagues in the private sector.”
“I am proud to say,” Dr. Hudson went on “that the American Medical Association has committed itself and its staff to stand by and be ready in any way possible to assist.”
This year, the War on Poverty has attracted an army of 325,000 volunteers. This is one volunteer for every 100 poor people in this country. An increasing number of these volunteers are doctors. We need--the Poor people of America need-- the kind of help and support which Dr. Hudson has offered with such an extraordinary degree of professional concern and enlightened citizenship.
In January, Dr. Hudson proposed that AMA and state and county medical societies launch a continuing program to improve existing health services to the disadvantaged and said, “I consider this kind of program a top priority AMA obligation.”
Well, I just want to say that whatever Dr. Hudson’s achievements have been as a private physician or as president of AMA, I believe he will be remembered 14 all Americans and blessed by all poor Americans for his awareness of their health problems and his determination to do something about them.
I hope all of you will follow Dr. Hudson’s example. There is much to be done.
The Community Action Agency in Cleveland is accepting volunteers now. We hope that you-- out of your concern for a healthier community, a healthier America-- and your pride in the medical profession, will be willing to enlist.
