A Housing Project and a Health Clinic--From Body Counts To "Personalized Medicine"

"YOU know every resident is supposed to take some responsibility as part of the contract in public housing, but it doesn't work out. There's a lot of work that's unattractive." Dr. Eva J. Salber, the Director of the Martha May Eliot Family Health Center in Bromley-Heath, one of Boston's housing projects, stopped to dig out an article on the Center. A coworker took up the conversation. "Yes, there's rubbish in the halls, and it's not uncommon to find vomit on the steps or urine in the elevators."

Dr. Salber found the report, "A Community Child-Care Program," which outlined the history and goals of the Center.

Community health clinics originated in Boston in the early 1920's with "well child conferences," weekly treatment centers run by a voluntary nursing agency. Authority for these centers, whose practice was limited to preventive treatment of children, was transferred to the Boston Municipal Health Center by the end of the decade, and in 1929 each of the city's three medical schools took responsibility for some of the clinics. At Harvard this job was delegated to the Professor of Maternal and Child Health of the School of Public Health, and he continued to organize the informal weekly treatment centers for thirty years.

When Dr. Martha Eliot was named to this Professorship in 1957, she saw that one of the centers could serve as a demonstration unit for the testing of new public health concepts. She picked out the Bromley-Heath Clinic because of its proximity to the Harvard Medical School. After her death, a grant from the Office of Economic Opportunity in 1966 led to the expansion of the center's activities from weekly sessions for treatment of children to care of children and mothers five days a week.

With a full-time staff of doctors, nurses, dentists, and social workers, the Clinic needed a full-time director. Dr. Salber, who was then a Senior Research Associate in Epidemiology at the School of Public Health and a Scholar of the Radcliffe Institute, said she "wanted to get back into the social realm of medicine." She laughed and added, "I don't ever remember saying, 'Yes, I'll take it.' But somehow I found I had the job, and by August 1967, I was working there full-time."

Dr. Salber had had previous experience with public health. She was born and raised in Capetown, South Africa. After graduation from Capetown University Medical School, now made famous by Dr. Christian Barnaard, she and her husband went to work in a demonstration health center in Durban on the east coast of the country. These federally-operated clinics had been founded in 1945 by Henry Gluckman, a Cabinet Minister in the moderate United Party government. (The United Party is today strongly pro-apartheid.)

Durban was divided into sections for whites, Indians, coloreds, and Bantus (Negroes), and Dr. Salber and her husband, also a doctor, were working in the Bantu township. Though facilities were good and the work "terribly exciting," apartheid raised moral problems. Just outside the township was a settlement of 6000 Bantu men on contract labor, brought in from all around the country. Mothers complained to Dr. Salber that their daughters were being threatened, and malnutrition was a problem among the huge colony of men. Yet to complain to the government from a medical and humanitarian point of view inevitably led to a criticism of South African politics. Dr. Salber recalled, "There just wasn't very much you could do about health without getting involved in politics. It was very difficult to do this kind of work and live with yourself at the same time. Even in the United States, medicine is very much bound up with politics, but you feel that the federal government is progressive."

In 1948 the United Party fell and the Nationalist Party, with a rigid policy of total apartheid, came into power. Increasingly repressive laws, disguised as "Suppression of Communism Acts," silenced opposition and further limited what doctors like Dr. Salber could do for the native and mulatto population. Most white South Africans, Dr. Salber explained, were "shocked, but then they accepted the laws. Who wants to go to jail without a trial? We could see that it was going to be increasingly difficult for people who thought differently than the government. If you didn't agree, you had to shut up and live with it or leave." Then she added, "And the majority live very comfortably."

Neither Dr. Salber or her husband could live comfortably, though, and they were particularly anxious that their four children not grow up in such an atmosphere. When the Harvard School of Public Health offered Dr. Salber's husband a position in 1956, they were able to get their visa and move to the States. A few years after they left the clinic in Durban collapsed.

The Martha Eliot Health Center serves an area of four and a half census districts--that is, about 17,000 people in Jamaica Plain and a small part of Roxbury. Because restricted funding has limited care to mothers and children under 21, only approximately 8000 residents are potential patients. The Bromley-Heath housing project, where the center is located, is nearly all Negro, with a smattering of Cubans and Puerto Ricans. The dilapidated homes around the project belong to Negroes, Cubans, Puerto Ricans, Greeks, and some old Boston Irish-Catholics. Many of these old Irish families are unwilling to come for medical care into the housing project where they'd have to associate with minority groups. Though the area covered by the center does include some well-to-do middle class homes, like the high rise Jamaica Towers luxury apartments, most of the people are chronically poor.

The Bromley-Heath project is run by the Boston Housing Authority, a federally-financed state agency. To qualify for housing a family has to have a certain low level of income, and once this income ceiling is passed, a resident of the project has to move out. Thus, the project houses a reservoir of families who are incapable of independently earning a living. Over half of the 1200 families in the project have no male head, and sometimes the three or four children in the family are fathered by different men. About 50 per cent of the families in the project are on welfare.

Their apartments do provide a steady supply of heat and clean water, while instances of lead poisoning from faulty pipes are fairly routine

Like too many welfare programs, the clinic had been organized simply as a handout. Little concern was shown for the dignity of individuals. It was that kind of attitude that turned the poor to quacks who at least remembered their names and soothed their emotional if not their physical needs. in houses just outside the project. But fewer families in these homes--one-third of them--are without a father. And fewer of the women running these houses are on welfare: 75 per cent of them as compared with nearly 100 per cent in the housing project.

The malaise of poverty is pervasive, restricting opportunities before they even arise. Some of the kids in the area around the Center have never even been into central Boston, though it's just a trolley ride away. Poverty also has been linked to disease. Federal statistics show that for a person under 45 with an income of $10,000 or more the average number of visits to a physician is 5.0 per year. When the income level drops to under $3,000 visits drop to 3.2 per year. Even with free medical programs this discrepancy remains. In England after fifteen years experience with the National Health Service, it's the higher income groups that make better use of the program. And at the Martha Eliot Center, Dr. Salber said, the children have many more minor ailments than normally: colds, respiratory ailments, chronic coughs. "We wonder if they get their medicine," she said.

Beyond this lack of care, the stigma of poverty inevitably leads to more physical and mental damage. For example, two reports of the center's social workers illustrate the kind of "disease" that doesn't occur in middle-class families:

"First seen in this clinic by Dr. Jones when the mohter brought Timothy, age 5, in for a swelling under the arm. She also brought in Susan, 11, and Kathy, 7. Susan is a very intelligent girl and has been chosen for the Latin School Test from her school. She has failed the eye tests and should be wearing glasses. She has very little sight in her left eye. She was referred to the doctor for an eye examination. Kathy also has eye difficulty.

Kathy is a bed wetter and mother wondered if it was because of mental strain. It seems as though when mother was in the hospital having her last child, the father molested Kathy. She was very ashamed and has not yet talked to ther mother about it, but has told all the children in the neighborhood as well as her sister who in turn told her mother. It was said that the children have been exposed entirely too much to sex. The parents still have a great amount of sex attraction for each other and hide nothing from the children." 2. Mother has been known to have psychosomatic complaints and poor health care follow-up. Brutality to child in past, burn on girl's face.

Other cases, running all the way from extreme brutality to "routine" separations have convinced Dr. Salber and her staff that to attack ill health in a ghetto must involve an attack on the social problems that result in physical and mental difficulties.

The poor are crisis-oriented. They neglect preventive care, and often delay in seeking help when a serious problem arises. Too often the practitioners they select are the local subprofessional quacks who have infiltrated and won the confidence of the neighborhood because they are racially and socially no different than the poor. The middle class, white doctors and nurses are different: They don't live with the poor, they just make their living from them. Even when the care is free, the delicate problem of winning the acceptance of the community remains. Dr. Salber and her staff organized a propaganda program during the past summer. News of the facilities and available care was preached from pulpits and spread through leaflets.

Merely to tell the poor of the existence of the Center, though, was not enough. Some kind of clinic has existed in the area for forty years, but the number of patients seeking care was far below the potential limit. Like too many welfare programs, the clinic had been organized simply as a handout: "Here's the center. Now you take it or leave it." Little concern was shown for the dignity of individuals. Patients had to wait in line to see a doctor who might or might not be the same one as last time. Examinations might be carried out in an impersonal manner that seemed to indicate to the patient that the system regarded him as just another burden. It was that kind of attitude that turned the poor to the quacks who at least remembered their names and soothed their emotional if not their physical ills.

The handout syndrome still characterizes welfare programs and, in particular, some of the clinics organized by city hospitals. The personalization of service was one of Dr. Salber's first steps as Director of the Center. Each patient is now given an appointment with the doctor of his choice, and to insure that they'll continue to come to the Center, patients are given new appointments before they leave. An attitude of "We care" has resulted in a tenfold growth in the number of mothers and children being seen.

Still there remains the question: Is this enough? Dr. Salber and her staff say it isn't. But they're bucking decades of medical tradition. "Our funders, the Children's Bureau of the Office of Economic Opportunity and the Mass. Dept. of Public Health, still demand body counts: how many did you see?, what were the diagnoses?, etc. Nobody asks you what community activities you and your staff carried out. This interaction of the staff and the community right in their homes is much more important in getting to the roots of the problems than are the number of people each pediatrician sees," Dr. Salber said.

Medicaid, the much heralded medical plan of New York State, falls far short of humanitarian medical practice, as Dr. Salber explained. A cumbersome registration program with a humiliating and involved inquiry into family finances may turn away many, and those that persist will often find the kind of impersonal attention that Dr. Salber did away with at the Eliot Center. Only when physicians take time to explain problems in laymen's language, only when the patient is voluntarily involved in deciding what the proper treatment is, and only when social as well as medical assistance is provided will patients willingly follow through with medical care and reverse the common notion that the poor are unwilling to cooperate. To treat symptoms and then send a patient back into the environment that breeds these illnesses is inhumane folly.

Dr. Salber has been seeking an expansion of the Center that would permit it to serve everyone in a family, not just children and mothers. "We are community-oriented, but we

While social workers can get to the root causes of the social, mental, and physical disease faced by doctors of the poor, a medical approach to social work can make the ticklish problem of "getting into" a family easier. It's not respectable to be poor or unemployed, but it's respectable to be sick.