This article originally appeared in Southern Exposure Vol. 6 No. 2, "Sick for Justice: Health Care and Unhealthy Conditions." Find more from that issue here.
We’re way up in the mountains in a coal mining town. We started out by putting on a health fair with medical students from Vanderbilt University. We’d seen the need of the people in our community that had been forty years and not seen a doctor. We couldn’t even believe that people had been that long without a doctor.
Then we organized a community health council and decided we’d build a clinic and see if we couldn’t get some health care for our people. Before that, we had one doctor that was eighty-four years old and used to work for the coal companies. When we started we thought that everyone would help us and be for health care.
But in order to get our clinic, we had to get approved by the county judge which he hated, and the county medical society. We had to scheme and beg and plead and feel almost like we are committing crimes just to get what is really rightfully ours.
One pretty high-up official in the state health department said to me, “Mrs. Bradley, you ’re fighting against the system!” I said, “If you can look around and see that this system has ever been kind to us, then I’ll quit right now!”
-Kate Bradley Petros, Tennessee
Folks in some parts of Tennessee and Virginia call the Student Health Coalition (SHC) the greatest thing that ever came to town. In the same places, people can be found who say quite the opposite. And to some people outside those communities, the SHC is a mystery, a rumor carried by the wind.
Why the controversy and confusion about an organization that has made a creative contribution to community health care in many areas of Virginia and Tennessee? The answer comes slowly. The story of the Student Health Coalition is long and complicated, and parts of it are disputed. But it is an important story with implications for both medical education and community health.
The essence of that story involves the SHC’s changing purposes, the changing times in which its blend of activism and community service took place, and the changing relations it had with various educational and financial institutions. Since its pilot project, the SHC has had three waves of activity. During 1970-71 the Vanderbilt and Meharry students invented the SHC; from 1972-74, a new generation of students institutionalized its more respectable methods and goals; and since 1975 the group has been groping for a new orientation.
In 1968, a handful of students and two faculty members at Vanderbilt Medical School created the original group, “Project Community Outreach, A Student Coalition in Community Health.’’ Their brainstorming began in September, 1968, after a representative of the Josiah Macy Foundation (of Macy’s Department Store) called Dr. John Chapman, then dean of the Vanderbilt Medical School and invited him to send a student to Macy’s conference on “The Changing Characteristics of Medical Students,” to discuss the growing “threat” of students taking over medical schools. Dean Chapman chose Bill Dow, then a first-year medical student and the only one interested in attending. At its conference that September, the Macy Foundation offered to provide funding for projects which would help channel the growing student radicalism in the nation’s medical schools back into the existing health care system.
After the conference, Dow returned to Nashville and met with fellow students and faculty. Standing out among those was Dr. Amos Christie, Professor of Pediatrics, who, with others, helped plan the first summer’s activity. They discussed their ideas with students and faculty from Meharry Medical College across town, and in March submitted a grant proposal to Macy for $20,000. The newly created Student Health Coalition eventually received a grant of $9,600 “to investigate community health care problems and formulate possible solutions and methods of implementation and to bring about changes in the health science student’s education so that it is more oriented to the total picture of the patient and his setting.”
Several factors helped the students launch the Coalition. Although these were the days of student activism and protest, the New Left movement barely touched Vanderbilt University and missed the Medical School entirely; yet it did leave its mark on the campus in a number of student groups which had a distinct community orientation. The War on Poverty focused attention on the poor South, and private foundations bid to outdo the government in providing funds for social welfare programs. A handful of teachers and students at Meharry and Vanderbilt with some history of social action founded the SHC as a way to become involved in the larger social movement.
When the students set out to investigate health care problems in 1969, they wanted to establish “an ongoing organization encompassing the entire university community... which [could] make itself available to investigate community, regional, or national problems.” But they had no organizational models to follow. Nor did they have a clear focus on a particular area of health care. Their original proposal suggested that “the institution of maternal and child care clinics, the reasons for and how to improve housing and rat control, and how to provide a more relevant health program in the public school curriculum, all are definite possibilities.”
During the summer of ’69, thirteen students did simple medical screening in Nashville and Williamson County, Tennessee, until August, when a few students and Dr. Christie went to east Tennessee, uninvited, to run a health fair in conjunction with the Presbyterian Church. At the health fair, a number of students took medical histories and did physical examinations of adults and children free of charge. According to Dr. Christie, “the whole trick of the thing was to make the medical screening process like a carnival that would be fun to go to.” While participating in the Presbyterian health fair in Clairfield, Tennessee, the students were impressed by a local health council, an incorporated group made up of local citizens and chartered to develop health care facilities in the community. The students saw the health council, and its goal of creating a community-controlled primary health care center, as a model that needed encouragement and expansion in other communities. As Bill Dow described in a reference to the White Oak Health Council, “A health council...has taken on the task of canvassing the community and registering people for Medicaid. They are interested in building a clinic and we feel like their potentials are quite extensive if they can find assistance.”
The students vowed to use the health fair — health council — community clinic model the following year. Janice Ambry, a volunteer nursing student wrote at the summer’s end, “The encounter [with problems in the real world] has forced my commitment to action, to work for change in a situation inbred with economic prejudice and white racism. A situation which robs children of Tennessee — and America — of good health.” Dow also made a sort of pledge: “I am extremely pessimistic with regard to the ability of the Public Health Department to meet its specified tasks, of the medical profession to meet up to its ethical and moral obligations of providing any, to say the least, good comprehensive health care for all, or the government’s ability to provide this care....This is the area in which I see the greatest need and at present am moved to direct my career toward.”
During 1970 and 1971, a core group of about thirty students from several disciplines led a larger group of 172 students on a drive to set up primary care centers throughout Tennessee. Under the supervision of physicians, Vanderbilt students operated health fairs for a week or two in ten communities. While these students took medical histories and gave physical examinations, usually in a school, other students helped organize local health councils. With health clinics as the focus around which poor people would organize themselves, members of the Coalition expected sweeping changes to occur rapidly. Some of them had read Regis Debray’s Revolution in the Revolution for theoretical guidance, and now envisioned a mass takeover by “poor people of resources and institutions vital to them.”
Sloppily, but enthusiastically, the students made visible progress. They cared little about administrative structure, and took pride in maintaining makeshift procedures for controlling finances and progress reports. They sat on the floor of Dr. Christie’s office in the Vanderbilt Medical School and spent hours making simple decisions, but were excited about having involved so many people in the process. In 1970 and 1971 they operated seventeen health fairs and eight special projects related to health care, helped to organize seven health councils and to initiate six courses at Vanderbilt Medical School, and laid the foundation for the subsequent development of Vanderbilt’s Center for Health Services.
Making the Coalition a project of the Vanderbilt Medical Center represented a radical departure from the University’s traditional emphasis on research and drew hostility from many faculty members. Vanderbilt was known primarily for its excellence in specialization and had no interest in community involvement. After forty years, Vanderbilt proudly boasted that it had produced only two general practitioners. Accordingly, in 1971, when the students announced plans for a bigger and better program to promote community involvement in rural health care, many of the faculty scorned them and nicknamed the Coalition “Christie’s Commies.”
In contrast, the students’ relations with the communities they served were quite good, especially with some of the less powerful citizens. Unlike their first fair in 1969, the students now entered communities only at the invitation of the local populace. They lived with them, held jamborees with them, and became their friends. During these years, the students looked to the local people for answers, and the local residents shared their way of living with pride.
Initial meetings were often intriguing to both students and community. Marie Cirillo, a Clairfield resident, recalls the first SHC health fair in 1969: “The people here were mystified by the whole thing. They crowded around the outside of the school house and watched the people go inside and later come out. Gradually they felt comfortable with it though, and liked it.”
When the students first came to Petros, Tennessee, in 1970, Kate Bradley, a local resident, remembers feeling both curious and enthusiastic: “The students had a funny way of involving poor people, and they actually got more people involved than I thought they could, but gradually they gave us confidence in ourselves.”
Members of the SHC recall the zeal with which they worked in those years. As John Davis, a former Coalition member, explains, “This was like our summer abroad, our contact with the real world...and we lived those days as if our lives were riding on the outcome.”
Ups and Downs
Throughout the summer of 1970, many of the students disagreed with each other on specific solutions to problems in organizing and working with the community groups, but they thrived on this conflict. They were learning to develop new and better health care systems and spokeexcitedly of their discoveries. Said one student, “Most of us have a better understanding of the politics of medicine....None of us will be able to remain in Vanderbilt Hospital, or our private offices, satisfied that we are doing all that a physician should do.” Another student comments, “The project has taught us much. Nurse practitioners and other paramedical personnel can and should be utilized to relieve the medical care problem. A doctor’s training should include experience with community medicine.”
After the summer of 1970, many students felt confident, even relieved, that they had demonstrated their ability to bring about change. The law students commented, “We gave people a better understanding of young Americans today and their concern for the poor and their dislike for the inequalities of the system.” Muffy Ecker wrote of her experience in Smithville, Tenn., “The project has proven to me and others not only that students can handle real responsiblity, but that they need to if college and/or professional education is to be of value. It still seems early to evaluate the long term effects of the project on the medical establishment, but it is exciting to me to see the potential begin to be realized of poor people in those communities to speak and act for themselves and begin to get what they really need on their own.”
By August of 1971, however, many students began to dislike and criticize what they had done, as their practical experiences in the Coalition failed to measure up to their New Left political ideals. One faction, dominated by medical students, believed that the Coalition was basically good and should continue unchanged. To them, providing health care was an end in itself, and the SHC was helping local people achieve better health services.
The other faction, led by community organizers and students outside the medical school, had decided that the SHC was an inadequate medical means to a revolutionary political end. Students in this group believed that the SHC had, in most cases, imposed health care as a priority on people who had more pressing needs. If health care had functioned as a catalyst for organizing around broader issues, these students might have been satisfied with the Coalition’s past activities. But they saw the health councils which they’d built as “medical PTAs” which were bogged down by administrative requirements and procedures.
The radical students didn’t believe that building small community institutions would catalyze people into demanding sweeping reforms and revolution. The clinics, which the SHC had helped to initiate, might temporarily disrupt local professional and political arrangements, but in due course they would run out of money and expertise, forcing the health councils to surrender their autonomy and be swallowed by the system. The more moderate students still believed that slow, methodical organizing would be necessary for implementing significant social change. The radical students responded by declaring that the Coalition should not become an established, respectable institution capable of slow, long-term building, because it would be unable to fight other establishment structures.
After this conflict, most of the more radical students left the Student Health Coalition. They departed, however, as decidedly different people than when they had first come to work with the Coalition. Many had finally acquired the practical experience that they had longed for in their early college years. Several secured jobs in Appalachia in which they could continue their commitment to broadbased social change. Others pursued traditional careers, but with an idealism they had tested, found useful, and learned to apply.
In place of these students a smaller group, with some carry-overs from the previous Coalition, began to turn the SHC into the more respectable institution which the earlier students had feared and scorned. With the Coalition’s budget now around $100,000 a year, funding sources and the university administration were also looking for a more stable and accountable institutional structure. To meet the growing need for respectability and long-term survival, coalition leaders organized the Center for Health Services as an umbrella organization to do fundraising, activity planning, and provide technical consulting to community clinics — and thus become the institutionalization of earlier Coalition efforts. The Center received an old building on campus, developed its own staff, many of whom were former Coalition activists, and began advising the ongoing SHC programs.
The members of the 1972-73 Coalition inherited from their predecessors the dispute about whether health care was to be the sole focus or just a means to a broader political end. The medical goal continued to be health fairs and primary care clinics, but the political goal was harder to articulate. Gradually, the students realized “that the most important contribution they could make lay in the area of community development,” and their decision to pursue this shaped the SHC for the next three years.
As the central project of the Center for Health Services, the Coalition helped map out a plan for long-term institutional change in the health care system. The students began to read Harry Caudill’s Night Comes to the Cumberlands and Si Kahn’s How People Get Power, quite a switch from Revolution in the Revolution. They streamlined their projects to serve fewer communities better with fewer students. As one Coalition member explained, “In 1971, the health fair visited nine communities. It was an exhausting experience. Long-term change in each community requires a concentrated effort. So, the decision was made to visit fewer communities this year.”
An event in September of 1972, when the new group of students was still consolidating, sharply illustrated the difference between the old and new students. Tricia Nixon, campaigning for her father’s re-election in 1972, visited the Center for Health Services. The new Coalition members were eager to meet with Ms. Nixon and discuss the urgent health problems of Appalachia. Some of the older graduates from the 1970-71 SHC heard about the Nixon visit and considered it the last straw, the final sell-out by the SHC to the Establishment. They returned to Nashville for the occasion, protested the meeting with signs (“Nixon Wants Votes, Not Health Care”) and demonstrated in front of the Center, which they had previously scorned.
Their leaflets claimed the Coalition’s methods consisted of “raising false expectations for long range medical care and then shattering those expectations.’’ They implied that the SHC was really a device for students to improve their own education at the expense of Appalachians. The leaflets also criticized the project as a ploy by the university to raise its own funds and to recruit students. It derided the Coalition for betraying its original “self-consciously anti-medical establishment attitudes.”
In defense of the SHC and its sponsorship of Nixon’s visit, Rick Davidson wrote a letter to the Vanderbilt Hustler, the student newspaper. According to Davidson, the protesters had “all worked in areas which we considered total failures,” proof that their criticism was invalid since the SHC had “proved effective in other communities where...the community workers were more intent on improving health care delivery, and less worried about organization for organization’s sake.” Davidson concluded his letter by comparing the protesters to the Nixon Administration: “It seems that the ‘protesters’ are no better than the Nixon administration as far as concrete proposals; neither group can get its mind off rhetoric long enough to come up with suggestions.”
The “respectable” Coalitions from 1972-74 were indeed concrete and productive. They organized seven health councils and a chapter of the Black Lung Association. They did useful studies on the financial structure of the pallet factory in Clairfield, taxation in a five-county coalmining area, and designs for medical buildings. Many of these tasks were clearly in the old tradition, while others were the outcome of previous efforts to organize health councils.
The SHC students in this second generation took a different approach, one which stressed technical expertise, planning and feasibility. They seemed to talk more and listen less but were interested in getting things done and improving their methods of solving practical problems like keeping medical records, conducting efficient health fairs and facilitating fundraising for clinics and community organizations. Accordingly, their year-end recommendations dealt mainly with the development of their own techniques. For example: “The entire question of supplies from the public health department needs to be reviewed in order to avoid mixup in the future.” “The special projects students should not live in one central place but should live in as many communities as possible.” “More time should be incorporated for follow-up either at the end of the summer or within the health fairs.”
The students did succeed in improving their methods, but they suffered from a high turnover in personnel each year. Emphasis on expertise and feasibility, they slowly discovered, led to depersonalization of the work. The widespread enthusiasm of earlier days was gone. Individual participants no longer had to commit themselves to local community people — since they believed the Center for Health Services would continue to maintain relationships with local projects that transcended the role of individual students. People plugged into specific tasks but did not understand that the overall project and the Center needed them to work for more than a summer; nor was there a larger social movement to educate them about how power works or motivate them to make greater commitments to social change. Statistics on participation reveal this trend, as student activism at Vanderbilt and around the country waned. Aside from project directors, only six of the fifty-six students from the 1972 Coalition returned in 1973, and only five of the forty students from the 1973 group returned in 1974.
One consequence of this high turnover was centralization of the SHC and development of a burdensome management that often fell on the shoulders of just one or two students. Bob Hartman, sole director of the 1973 East Tennessee Project, expressed his frustration when he wrote, “The directorship drastically needs to be split among several students with as many former workers as possible trying to pass on their experience to some of the new folks.’’
Because of the increasing complexities of the health care bureaucracy and funding requirements, the students became engulfed in red tape and professional jargon. To complicate the situation, some doctors, lawyers and administrators in the Center for Health Services and the East Tennessee Research Corporation, many of them veterans of the SHC, began to echo the foundations’ and government’s demands for fiscal feasibility. A danger of the students’ consequent preoccupation with technical expertise and bureaucracy was their tendency to overlook crucial aspects of clinic development and community organizing, especially local leadership training and community education. As financial problems increased for the original SHC-inspired clinics, internal strife heightened within the clinics, and administrative and professional staffs, many of them SHC veterans, began to clash with local health councils over new directions and policies. As problems became more tedious and complicated, the Center seemed less able to channel the energy of students into productive and experimental projects, as the SHC had done in the past. More and more of the program became wrapped up in solving technical problems connected with the survival of existing councils and clinics, and less and less in putting students into the field in creative ways.
In spite of these roadblocks, the students operated the Coalition machinery well enough to organize four new health councils during 1974, but SHC leaders expressed anxiety about the future. Private foundations no longer considered the students’ work as legitimate and hesitated to fund the Coalition’s activities.
In 1975-76, several factors sent a third generation of students into a tailspin. The economic crunch of 1973 had caught up with funding sources, which reduced their budgets for both clinics and student projects. In addition, grant money that used to come directly to the SHC, to use as it saw fit, was now channeled through the Center for Health Services, which put increasing restrictions on the students to develop successful “financially feasible” clinics. The SHC and the Center clashed particularly over the issue of selecting communities for the summer projects. In the past, the Coalition members had been free to go wherever they were invited and set up a health fair. Now, the students were being told that they could not hold health fairs wherever they were invited — by the same people on the Center staff who a few years earlier had roamed the state freely holding fairs and setting up clinics.
The student leaders also began to have difficulties in recruiting participants for the summer’s work. The days when activism was popular had passed and current students wanted simple tasks that they could easily perform. The drying up of both funds and student participation distracted and disrupted the model of clinic development that the Coalition had previously employed. The Coalition’s resulting preoccupation with fundraising has meant that there is less time to look for communities to work with to involve energetic students, and to develop effective methods of community follow-up.
In spite of these difficulties, a small group of dedicated students has tried to continue the health fair/community clinic model, while simultaneously developing projects in occupational health with copper miners, local Health Systems Agencies (HSA) activities, and doing flood control research. As always, the Student Health Coalition continues to hammer out its new identity as each year’s students and community participants determine the scope, content and vigor of the Coalition’s activities.
Meanwhile, the Center for Health Services has expanded its role as an umbrella for a variety of service programs, including rural legal aid, agricultural marketing, legislative research, and technical assistance to clinics. Its budget has dramatically increased, while the SHC’s has dropped. A glance back through the Student Health Coalition’s decadelong history reveals one of the country’s most successful and productive student-controlled community health projects. Involving over six hundred Vanderbilt and other students in its activities through the years, the Coalition has worked in over thirty communities throughout Tennessee and Virginia and helped to initiate more than ten primary health care clinics. The Coalition grew and flourished during the heyday of the student movement of the 1960s, when there was an abundance both of money for innovation and idealistic students with boundless reservoirs of energy. In spite of the slackening of student activism and disinterest by funding sources, the Coalition has bravely tried to continue its health reform efforts in a more institutionalized and scaled down way.
If there is a message in this story for colleges, the government and foundations, it is this: that students, if given the resources, the responsibilities and the freedoms can achieve constructive social change in the health care system. For students, the message may be conversely: if students in community health projects want to ensure their usefulness and freedom to experiment, then they should maintain some authority in their relations with outside experts and funding sources.
Even more important than the Coalition’s projects and activities over the years are the students who threw themselves headlong into its activities, inspired by the vision of community-controlled health care delivery. As the students’ eyes were opened to the politics of medicine in rural America, they, too, were changed. Many of them have gone on to staff clinics across the South that they themselves had worked to initiate. They work on day to day, still carrying the original vision of the early Coalition era.
Ironically, the Coalition began as a project of the Macy Foundation to stem the growing radicalism in medical schools and to coopt increasing student attempts to take control of medical education. On the Vanderbilt campus, the Macy money had the completely opposite effect. It helped to produce a generation of students with high ideals and practical experience in changing both the medical education process and the health care delivery system.
That student activity produced a generation of people (1970-71) with high ideals for social change. Upon graduation from Vanderbilt members of that generation applied these ideals in different forms, some becoming health professionals within the formula they had helped to invent. Those interested in community development passed on their formula to a second generation (1972-74) of students that became even more productive with it than the first generation had been. But after funding sources lost interest in financing student and community projects, members of these generations constrained a third generation (1975-77) of students. They took the position of funding sources and through the Center for Health Services, allied themselves with the University they had once fought against. Thus in a sense, money fostered a radicalism and then, through the agents of that radicalism, constrained it once again.
Kevin McDonald, who is a senior at Vanderbilt University, worked with the Appalachian Student Health Coalition in 1975, directed the Coalition in 1976, and served on the Board of Directors of the Center for Health Services from 1976-78. (1978)