Address Evaluating the War on Poverty to the American Public Health Association

New Orleans, LA | October 21, 1974

Looking back, I thought one of the most extraordinary things about that program was the fact that when Congress started it, when I got the job to try to manage it, no one thought that health or the provision of health care, would be an important aspect of that War. There was no provision in the original OEO legislation calling for the creation of health programs...We found out right away that for the customers, for the consumers, for the poor, health was a matter of primary importance.

Thank you very much, President Kerr. My good friend, former Surgeon General, Bill Stewart; Dolores Huerta, Viva! Dolores! -- Reverend Jesse Jackson; other distinguished persons here on the speaker's platform; ladies and gentlemen.

First of all I'd like to say that traveling 10,000 miles from Moscow in the Soviet Union to be here this morning is well worth the effort. I'm glad I came. I'm glad I came because I don't know of any national organization in our country which would have the nerve to announce in advance, and then give speaking time, to three people as radical as Dolores Huerta, Jesse Jackson and Sargent Shriver! And because I am deeply honored to be on a speaking program with them, and with your President, and because I am overwhelmed at this magnificent audience of men and women, of black and white, of old and young, of sitting and standing, that I want to say, again, I am delighted to be with you, honored to have received your invitation, glad to be speaking to you this morning.

But what excuse do I have to speak to you I keep asking myself. By what right does a mere lawyer get up here and presume to talk to Surgeons General and Professors of Microbiology, not to mention experts in nursing and in many other aspects of the delivery of medical care. I think one of the greatest things about this country is the fact that perhaps you're not too surprised that a lawyer speaks, because regardless of whether I'm a lawyer or a doctor, I am a citizen, a consumer of the services that you offer. And it's high time, not only in the area of health, but also in my own area, the area of justice, that the voice of the consumer, the voice of the customer, be heard throughout the land.

Parenthetically, I'd like to say that I said the same words to the American Bar Association just last month, excuse me, two months ago in August, to the American Bar Association at its annual convention. I was asked by the President to conceive of and present a program 3-1/2 hours long involving films as well as speeches on the subject "The Delivery of Legal Services to all Americans". And I can assure you who work in the area of health that we who work in the field of justice and law have many problems, very comparable, if not identical, to yours. We put $140,000 into that program. We got three hours of film. That film will be condensed and shown on television this fall, public television. It's being arranged also so that it can be used in every law school in America. And I'm pleased, really, that the American Bar Association supported such an effort to bring the realities that most Americans face when they look at the law, when they try to get justice, to bring those realities to the students in the law schools before they ever graduate because we cannot hope to be able to deliver justice on an equitable basis to all Americans unless we start in the schools by teaching the young lawyer what it means to be an American for whom there is no justice. The same thing, I believe, applies in the area of health. We've got to bring forward to, the medical students as well as to many others, what it means to be an American who cannot get help.

For me, it's an auspicious year. It's the 10th anniversary of the start of the War Against Poverty. And looking back, as I was instructed to do by your committee, to make a brief evaluation, looking back, I thought one of the most extraordinary things about that program was the fact that when Congress started it, when I got the job to try to manage it, no one thought that health or the provision of health care, would be an important aspect of that War. There was no provision in the original OEO legislation calling for the creation of health programs, nor was there any provision calling for the creation of legal programs. Instead the original emphasis was mostly on jobs, on income, dollars.

And so at the very beginning we had a big Job Corps and we had a Neighborhood Youth Corps and we had Community Action Programs and VISTA. But there was nothing specifically about health. But thank God we did have eyes and we did have ears, so we could see and we could listen to the poor who came into the Job Corps and into the Neighborhood Youth Corps, etc., and what did we find? We found out right away that for the customers, for the consumers, for the poor, health was a matter of primary importance. I'll never forget at one of the earliest Job Corps camps, there was a white youngster from Kentucky, and he wouldn't eat anything. He didn't talk very much and people thought he was a little bit odd, at the beginning. After about a week, the dentist came to that camp and when the dentist inspected this youngster's mouth, he found that that boy had something like 18 cavities in his teeth, three abscessed teeth, and that he actually couldn't chew the food that was being given him to eat.

We found scores, hundreds of young American, at 15, 16, 17 years of age who were labeled "retarded" but in fact, were suffering from the fact that their eyes were so bad, they had no glasses, they couldn't read. So that in school, they were flunked not because they were stupid, but because they hadn't had a medical examination.

We have found victims of malnutrition, not only people who were scrawny, but people who were fat from the wrong kind of food. In brief, we found that 80% of all the young men and women who joined the Job Corps had never seen a dentist or a doctor in their lives.

Within one year after the start of Head Start, we were spending $40 million just to do remedial medical and dental work on children 5 and 6 years old. So the question immediately arose, Well, what should we be doing in regard to these youngsters? We certainly realized immediately that merely doing remedial work was not enough. Then one day two doctors arrived in our offices, -- Dr. Jack Geiger and Dr. Count Gibson, from Tufts Medical School in Boston. Like good doctors in a medical school, they had heard that there was a new Federal program, so they were looking around for some money. They wanted $100,000 for a demonstration grant. They talked to a wonderful woman named Lee Schorr, and she said "Look, we're not in the business of demonstration grants, we need projects which will have a mass effect on problems of poverty. Give us a program for a million dollars." At which point both those doctors nearly had coronaries.

They weren't from Harvard Medical School, or Yale, or Stanford, or even from Chicago. They were just from Tufts. And they never had the nerve to ask for a million dollars. But they went to their drawing board and came up with a good idea. They came up with a proposal to start a health center in the Columbia Point area of Boston, which is one of the poorer sections of that city, and simultaneously a health center in- one of the poverty stricken parts of Mississippi, a town called, Mound Bayou. And then to compare the health conditions in these two places, urban and rural, north and south.

With the help of some far-sighted doctors, we said "Yes" and we gave them the money to start. Then suddenly we found others coming in. Not the establishment places, but for example, the Denver Public Health Department. They began coming in with similar requests. Within the first year, we had 30 of these Neighborhood Health Centers underway. And as soon as we started inspecting once again among the poor being serviced through these centers, we found out that the services were not enough. We found out we needed narcotics programs, we needed alcoholism programs, we needed family planning programs, we needed emergency food and medical services programs. For example, down in Mound Bayou in Mississippi, when Jack Geiger went down there (he lived in a trailer) he found himself as a doctor within the last month, writing out prescriptions, not for drugs at a pharmacy but for food: He was giving prescriptions for food to the patients at that hospital, because as a doctor, he saw that the problems they had were not, let's say the problems of the rich -- being overweight -- but the problems of the poor; -- hunger, malnutrition, untreated physical handicaps such as poor eyesight, poor hearing and multiple dental problems.

I had thought, like most Americans think even today, that America has the best medical profession, the best medical service in the world. And I guess it's true, perhaps, that for people at the top, American medicine is as good or better than anywhere in the world. It's great, also, if you have some peculiar disease on which research can be conducted. It's also good if you're a scientist and you want to do some very difficult abstruse work in molecular biology -- bench research -- in a very tall building under controlled conditions. It's very good for you. You might win a Nobel prize.

But the reality for the majority was clear. They could see the Massachusetts General Hospital with their own eyes, looking out the front door of their own house, yet they couldn't get a doctor. The Prince of Arabia or the King of England, so to speak, would come all the way from over there to go to the hospital that the poor people a mile away couldn't get into. In Watts, the ghetto area near Los Angeles, in Watts they had a saying. They said "Are you ten dollars sick?" And this is what they meant. They meant, and let me say ten dollars is a lot of money for them, they meant that unless you were sick enough to want to spend ten dollars; seven dollars for round-trip taxi fare to get to the nearest medical center which would receive you, that was a one-hour round trip, no public transportation available, unless you wanted to spend seven dollars for that and three dollars for the minimum clinical fee, you were not sick enough to get medical attention. Ten dollars sick: It was a sad, tragic commentary on the state of American medicine.

And so, we did start Neighborhood Health Centers and some of these other programs I mentioned. In 1969, the Secretary of HEW said that America needed at least 1000 such centers. Today we have 300. And if Casper Weinberger, well known as "Cap, the Knife", has his way, we soon won't even have 300 such centers!

The fact is that here in America, we don't need any more demonstrations. We know enough now... we know enough now, not only about the right way to deliver services, but we know enough now about the services which are needed in order to undertake a massive, national program to change the structure for the delivery of medical services in America. It is no longer justifiable, if it ever was, that we who are first in wealth in all the world, should be among the medium, if not the worst, in health in the whole world.

Now some people think that the passage of a National Health Insurance Law is all that's necessary. Let me say, I disagree. First of all, a great deal depends on the kind of law that gets passed, and some of the proposals would do very little more than to guarantee all the medical doctors that their fees would be paid promptly and in large amounts by the government.

First of all, then, we need a national health insurance act or law, a national health security law, if you will, which will guarantee that the people who need the money to pay for services get the money to pay for the services. And that does not mean the very rich who can pay for them right now, it means the moderate income person and the poor person in our American society.

Secondly, even if we have such a law, we have not, let me say, we have not solved the problem. We have not solved it unless we get structural changes in American medicine. Now you all are being very patient here this morning, very responsive, I appreciate, it greatly, but you also must be getting very tired.

And so I want to say on the record that I subscribe to and support all the things I wrote out in my speech this morning, but I'm going to take out the whole middle part of it and jump right to the conclusion.

The middle part I might say just had some more things that we learned from 0E0 which are applicable today. I'll just mention one of them, for example. We came up with the idea that the consumer, the customer ought to be involved in the planning of the medical hospital or the medical clinic.

Well, I think that the idea is more valuable today even than it was then. We know today that consumer participation can be corrupted, you can have tokenism, you can have a committee that looks like consumer participation but which is really not consumer participation, I'm against that. I'm in favor of having the consumer involved from the top to the bottom in the whole process, on the board of trustees as well as with respect to the nursing service or the sewage disposal. That's just one of the things that is in my written text which I'm going to eliminate. I mean from giving you, not from supporting. I'd like to jump to my conclusion. I'd like to suggest three or four specific things that all of you, I believe, could play a large role in achieving.

The first thing I'd like to suggest, this is rather presumptuous, I hope you will forgive me, but I would like to suggest that this organization, this audience, an audience as varied as I described when I first stood up here, that this organization become the voice of American medicine instead of the AMA. Is that all right? Are you in favor of that? O.K.

Now, Dolores Huerta made the point eloquently when she said that health is a matter of public right, not of private profit. And this organization stands for that, public health not just private profit. So I suggest, I urge, the existing President, and the incoming President, both of them men of eminence, distinction, scholarship, experience, erudition and power, to take on the job of making your organization number one.

Now the second thing I suggest is that this organization "gird up its loins" as the Reverend Jesse Jackson would say, gird up your loins and come out fighting for a real national health insurance act, which would remove all financial barriers to heath care in this country. Health is a basic human right and it should not depend on how much you got in your wallet as to whether or not you get health services. I'd like to repeat number three, that we need structural changes, not just a new act. Now what do I mean by that? I mean at least this mean at least number one, that primary care instead of catastrophic care should become the focus of American medicine.

We need an emphasis on preventive health-services. We need men and women who will specialize in giving, you might say, general services, family practice to the people of America.

Secondly, we need community based services and by that I mean distribution centers, the way we started them at OEO, neighborhood distribution centers, where health can be given to the people, where the people are rather than making the people go someplace else to get it.

Now some people in medicine think that's radical. I don't. I think it's American. And I cite as my example Sears Roebuck. Now Sears Roebuck does not put its store in the most inaccessible place in New Orleans. It puts its store where the customers are. We've got to put our medical distribution centers where the customers are, which means in the ghetto, it means out on the fields where the farm labor workers are. It means to try to perform medicine and the delivery of medicine to conform to the needs of people.

The third point. I think we need changes in the way we train manpower and womanpower for American medicine. We need the medical schools to start producing different types of doctors. And by that I mean not to diminish or degrade in any way the necessity for research, but I do mean we need to require medical schools to turn out people who will supplant, you might say, or replace what we used to call the general practitioner. We need men and women who will go out and work with families. And who will go out, for that matter let me just add, into the rural parts of America. We need new nurse practitioners. That is, women and men, nurses who are able to go out and deliver, let me say, about 75-80% of all the health care thank God that most people need. Now some people say these ideas are radical but they're not radical at all. Let me tell you where medicine has been practiced this way for a long time. It's been done in the greatest, socialized enterprise we've got in America, right in the Army, Navy and Air Force. I was in the Navy for five years. I was on a submarine for 3-1/2 years. They didn't have enough doctors to put a doctor on every submarine in the United Gates Navy and they never will. But we had what they call a Chief Petty Officer. And let me tell you he could do practically anything that was needed for the health of the men on that submarine for 60 days at sea. One of them, I'm sure some of you as old as I am will remember, performed an appendectomy at sea and it was a success. These people became Chief Petty Officers. None of them were M.D.s, but they could take care of the vast majority of everything that affected these men while under wartime duty. That can be done in the civilian side.

We need family health workers, people who go out to where the families are, not just bring them planning, I'm with Dolores you understand. When Dolores said she had ten children, Jesse turned to me and said, "Sarge, how many do you have?" Well, I said I'm very happy that I'm just half as successful as Dolores. I have five. And he said, "Oh, my, that's too bad, you topped me, I only have four."

But I'm talking about family workers who go out qualified to give that kind of help and guidance where it's needed, but also qualified to stop lead poisoning where it's occurring, to deal with the nutrition problems of families, to deal even with the housing when the housing itself is promoting or creating unsafe or unsanitary, unhealthy conditions.

Finally, I'd like to suggest that we pay special attention to rural America. Hundreds of counties in America have no doctors. And I suggest in that connection that we begin to explore the possibility of requiring, that's a big word, dangerous, word requiring medical schools' students to donate two years of medical service for the medical health of America.

Let me say I'd be perfectly willing to have the same thing apply to lawyers. Let us not forget that almost 80% of all the support for medical school budgets and for hospitals in America come from the public, and if the public supplies 80% of the facilities and salaries of the people who are needed to produce doctors, it seems to me, then, that the young doctor can at least turn back a couple of years of effort in response for that gift.

Finally, let me say that health has become the second largest industry in this country. The national budget for health and health-related things is now bigger than the defense budget, and I suggest, therefore, that this organization and everybody in the health field stand up tall. Don't be afraid to take the responsibility for the vastly important area in which you're involved. I think this is essential because I'll never forget the words spoken by a young black, radical when we dedicated the Watts Health Center in LA almost ten years ago. His name was Tommy Jacquette, pretty famous fellow at that time. And he said, "This is a magnificent building and operation. It will reach 30,000 people here in Watts. But there's 350,000 people in Watts. What about the others? The people who are not reached by this center?" He said if you only put up this one center and show what life could be like and then fail to deliver for the others who need it just as badly, you will be sowing the seeds of revolution.

I say that Tommy Jacquette was right. There are ten centers needed in Watts, but there is still only one! I say we can't, as Lincoln said, be a nation half slave and half free. We certainly can't be a nation half healthy and half sick. We need leadership to change the topography, if you will, of the American medical system. We need leadership which will say, "yes, we must respond because we have the ability and the money to respond." We don't want coercion, as I see it in Russia, but we do need leadership.

Now, we're not going to get it, sad to say, from the White House. Nixon was against it. And our current President is not much more favorably disposed toward it, to be as kind as I can. After all, he did vote against Medicare and Medicaid, he did vote against Head Start and the Job programs and unless he changes totally, we're not going to get the leadership we need from the White House. And so I turn again to you. I say help America to become all that America can be. Our country is by far, still, the most wealthy, the most resilient, the most generous, the most responsive with the best educated people in the world. If your organization will open the eyes of America to the realities in the area of health, if you will speak out as you can, to penetrate the ears of America, then you will be able to lead a necessary revolution in the delivery of health care, health service to all Americans. I wish you well in that effort. I'm sorry I've talked so long, but I was a week in Moscow and over there, they don't let you say anything.

Thanks a lot.