The African American Contribution to Health Reform
by Willie D. Davis Jr., Ph.D.

Health Promotion is the process of enabling people to increase control over, and to improve their health. (World Health Organization, 1986)

In 1984 at the invitation of the Ministry of Health of Kenya, I visited with the Elders of Kirinyaga village. They also served as the Health Committee. As we discussed health issues, plans were laid for a young couple to be married. I questioned the elders: What does a wedding have to do with health. I was politely informed that physical and mental health was not the only aim of health, but individual and community well-being is also part of the definition of health, which is echoed by the World Health Organization (WHO).

Many poor and minority communities in the US do not control their own healththough poor health, poverty and minority status are generally related. The statement that Necessity is the Mother of Invention has great applicability for these communities. Lack of affordibility, language and cultural barriers and limited knowledge of disease prevention has made it necessary for communities to develop empowerment strategies to improve their health when the official health authority cannot or will not for various reasons. There is a growing body of literature that demonstrate that community based intervention can be effective in the prevention of disease as well as in the promotion of good health. These efforts have an impact on the nations health by providing baseline data that communities or organizations in the community can modify for their own health needs.

As part of this tradition of self-reliance, a number of black organizations have over the years been planning and developing programs to improve the health of African Americans. The strategies employed are in general based on community based initiatives using organizations to push the health agenda, especially the church. Community Based Organizations have been instrumental in this regard by empowering people who have been essentially ignored except for dissertation studies.

Historically, religious organizations have been an economic base for development of credit unions, banks, private schools, and hospitals as well as aid organizations and the development of a corp of politicians. Other organizations like the NAACP have been instrumental in the fight for Civil Rights and the power to vote. Organizations such as the Black Panther Party in addition to pushing the Civil Rights agenda have developed model breakfast programs which have become the cornerstone of present day school breakfast programs. The Association of Black Social Workers have helped to shape national welfare and child adoption policies. Recently, the National Black Leadership Summit has developed a plan for black political, cultural and economic empowerment as well as the Million Man March and a health agenda.

At the state and local level, many churches and other organizations, including fraternities and sororities as well as those listed above, have local chapters that form community health committees to supplement their original mission. These health committees have responded to four major issues in the African American community.

  1. Health Reform: African Americans are grossly underinsured or uninsured leading to a strong reliance on emergency care and a strong adherence to of taking care of their health only when sick which is often too late.
  2. The lack of health professionals and para-professionals.
  3. The Fact that African Americans are dying at much greater rates than their white counterparts especially from preventable causes such as AIDS and Homicides
  4. A growing trend toward using a prevention model utilizing community based organizations.

HEALTH REFORM
President Clintons Health Reform package was heavily influenced by the Congressional Black Caucus and Coalition 93; a group of black organizations including the Black Caucus of Health Workers of the American Public Health Association, the National Association of Health Service Executives, the National Medical Association, the Black Nurses Association, the National Association of Black Social Workers, the National Dental Association and many others.

The set of principles drafted by the Congressional Black Caucus and Coalition 93 include: universal coverage/accesscoverage of every American; federally mandated civil rights standards; strengthened and expanded community-based infrastructure; increased federal authority/oversight over state health care reform; increased numbers of African American health care providers; establishment of a basic benefits package tailored to the needs of high-risk groups and the under served, and establishment of quality control mechanisms that reflect the African American community interests and needs.

Health Reform as envisioned by President Clinton has been an attempt to wed the socialized form of health care which uses community empowerment techniques to a competitively driven capitalistic system. China, the Soviet Union, Tanzania, and Cuba have used mass prevention campaigns to improve health outcomes generally through mass mobilization through health education. Canada as well as Great Britain were able to use the socialized medical model with success because of their status of developed nations, however, as the economy suffers so does the health care system. It is expected that competition for the health care dollar can avoid this decrease in health care in America as well as control health care costs. An aging population, less employee based health insurance, catastrophic disease cost and the cost of providing emergency care contribute to higher health care costs. Two measures have surfaced to control cost: Prevention of disease and Managed Care.

PREVENTION
Most studies show that an ounce of prevention is worth a pound of cure, The idea of prevention has had its most dramatic impact on the nations health in the areas of AIDS and violence, each of which can be prevented by lifestyle changes. This is in contrast to developing countries where infectious diseases are the greatest killers. In America it is those diseases most impacted by lifestyles which kill. Sexually transmitted diseases, heart disease and stroke, and cancer, can be eliminated or at least controlled by lifestyle or behavior changes. Prenatal care can reduce infant mortality and diabetes can be managed. Aggressive outreach can prevent persons suffering from mental illness from further deterioration of both mental and physical health conditions.

MANAGED CARE
Managed Care is defined as A comprehensive, planned, and coordinated program of health care with emphasis on preventative care. Managed care is usually associated with HMO programs, Physician Sponsored Plans and Clinic-based Plans. (italics mine) In Michigan Medicaid recipients are assigned to a medical home where their health needs are addressed. This enhances a well care system rather than sickness care, which promotes the idea of prevention. It also is a component of health care reform and a move toward universal care through increasing eligibility by expanding income guidelines and promoting community based intervention.

COMMUNITY BASED INTERVENTION
The Black communitys response has been overwhelming. Perhaps the most far reaching has been that of the Nation of Islam whose adherence to proper diet, spiritual awareness and healthy lifestyle disdaining alcohol, tobacco and other drugs has been exemplary as well as developing a national wellness campaign with the National Black Leadership Summit. A breakthrough which underlines their growing importance in national health concerns is the establishment of clinical trials from the National Institutes of Health for a cure to AIDS developed by the Nation in tandem with researchers from Kenya in Africa.

A second strong effort has been the publication of a document entitled Health Authority Model: A Health Delivery System for Under Served Ethnic Minorities. This effort, funded by the Kellogg Foundation and designed by the Black Nurses Foundation with assistance from the National Association of Black Social Workers and other health professionals, outlines a Managed Care model while Using the principles of primary care and emphasizing preventive health services, continuity of care, and responsiveness to culture competency requirements of ethnic population, the Health Authority Model is a viable alternative to replace the current fragmented health programs financed by federal, state, and local governments, for addressing the needs of medically under served populations.

This model combines the involvement of public and private sectors at two levels; finance and service delivery. The overall plan is to pool public and private resources to deliver services to the entire population at the state level; a true attempt at health reform. In Michigan, the Departments of Public Health and Mental Health have combined with the Medical Service Administration of the Department of Social Services which administers Medicaid. The combined Department of Community Health will become a health Care purchasing agency. This model of a purchasing pool for Medicaid recipients mirrors the Health Authority Model at least for the Medicaid Population.

This approach has been tried by the Brazilian government. In this system the Federal government provides insurance for all employees from employee contributions, a privatized system for the wealthy and an insurance welfare plan for the indigent. The similarity to President Clinton's health reform package is striking. It was as though that the vitality of the capitalist competitive spirit would overcome the failing of the Brazilian efforts as well as the deficits in the Canadian model.

Overall the trend to improve the health of minorities and other populations has been to turn over the provisions of health services to community based organizations and reduce reliance on the public health system. Community involvement is a key component of the Health Authority Model. Within the African American Community these include the church, the family and social organizations described earlier. A 1986 article entitled In Black American Communities, Volunteer Health Cadres outlines the impact of these agencies. Federal, State and Local health entities recognize the importance of these organizations in service delivery as well as controlling health care costs in a managed care system especially in the area of outreach.

The Centers of Disease Control has recognized the value of Community based projects. In a soon to be published document entitled Promoting Healthy Lifestyles in Inner City Minority Communities outlines step to empower the community to promote health and prevent disease. Of recent vintage has been the impact of including violence prevention as a health promotion strategy by taking the issue of interpersonal violence to health planners. Many community based organizations have had successful interventions by using models of Health Education and community involvement in health campaigns. Over the first half of 1994, the homicide rate has decreased by 12% nationally.

With the move toward community based organizations involved in Health Care Reform, Outreach and Health Education activities, service delivery and managed care, a need for networking with these various groups emerges. The advent of computer technology for networking and interphrasing makes this possible. Community based clinics, hospitals, physician offices and community based services can link together to reduce duplication of services, share facilities and resources, utilize multi-service facilities (one-stop shopping), training, tele-conferencing and increased communication. Dr. Nancy Milio from the School of Nursing at the University of North Carolina outlines these exciting possibilities in her new book.

In conclusion, African Americans have contributed greatly to health Reform by developing a health care model under the following outline by:

  1. Developing concepts of wellness not sickness care and develop our own health care alliance.
  2. Mandating health reform with universal access and health insurance with prescription coverage.
  3. Developing a service delivery system with the following components:
    1. Health authority model-managed care and linkages between private and public funding and service delivery utilizing a clinic model linking
      1. low cost clinics across the state
      2. increase health para-professionals
      3. focus on delivery by nurses
      4. reaching the inner city
      5. informational model - community linkages through personal computers
    2. Training to increase health professionals and para- professionals.
    3. Utilize national organizations including the church, NAACP, Sickle Cell Groups, Black Nurses Association, the National Association of Black Social Workers and other organization with state and local chapters and representatives.

Willie D. Davis, Jr. has recently retired from the State of Michigan as the Program Manager of the Medicaid Managed Care Ombudsman Program for the Michigan Department of Community Health. He also spends a significant amount of time on the African American Male Health Initiative developing community health promotion with the Lansing Association of Black Social Workers, and working for National Health Reform with the National Association of Black Social Workers and other groups.

He is the co-president of the Lansing Chapter of the National Black United Front .


BIBLIOGRAPHY

  1. Summit '93 Health Coalition, "Coalition Call Newsletter" Volume 1, Number 1, July 1994.
  2. National Black Nurses Foundation, Inc., "Health Authority Model: A Health Delivery System for Under served Ethnic Populations" Kellogg Foundation, 1995.
  3. Liburd, L., Cottrel, R., Davis, W., Schlaff, a., et.al., 'Promoting Healthy Lifestyles in Inner-City Minority Communities", U.S. Department of Health and Human Services, Public health Services, Center for Disease Control and Prevention.
  4. Davis, W., "In Black American Communities, Volunteer Health Cadres", Hygie, Volume V, 1986/3.
  5. Goldstein, A., "The Aspen Dictionary of Health Care Administration. Aspen, 1989.