The Harbor Health Services Story reaches into the last five decades. It is a story that did not witness the community health center movement, but defined it. It is the story of four distinct health centers, a host of community programs, and an elder service program working toward a shared belief that everyone has a right to affordable, high quality health care in their community. What started as small group of dedicated staff and a couple of thousand dollars in expenses and revenues has grown into a large, respected non-profit organization and national leader in healthcare. With a staff of over 450 people and a $40 million annual operating budget, Harbor Health serves dozens of neighborhoods in the Greater Boston area and communities on Cape Cod.
We care for over 20,000 people offering medical, dental, and social services and a host of community programs including a vital food pantry and WIC program, on-site day care, domestic violence counseling and support, a substance abuse prevention program, and a youth violence prevention program. Since the mid 1960s, we have watched children in our pediatric departments grow up, have healthy families of their own, and return to our health centers for generations. This story, 45 years in the making, describes how Harbor Health contributed to some of the largest developments in the healthcare field and helped shape the community health center movement.
The story begins, literally, at the beginning. Dr. Jack Geiger and Dr. Count Gibson founded the first community health centers in the nation in one urban and one rural community.
What started as small group of dedicated staff and a couple of thousand dollars in expenses and revenues has grown into a large, respected non-profit organization and national leader in healthcare. The idea for the centers, inspired by Dr. Geiger’s experiences in South African, was borne from experiences providing medical care during the civil rights movement. Dr. Geiger’s vision sought to confront abject poverty and medical disenfranchisement. Yet, Dr. Geiger believed a health center would not only provide much needed medical relief and social services but that these centers were a path toward community empowerment and direct citizen action. In the vision, people would lift themselves and their families out of poverty and bring their neighbors with them. The health centers were not the end; they were the means.
Columbia Point Health Center, 1965-Present
Located on an isolated and impoverished peninsula in Boston, Massachusetts, in 1965 Columbia Point Health Center became the first operating health center in the nation. The area itself had once been a municipal waste site and later a bleak stretch of neglected housing projects and vibrant, but largely forgotten families. Despite its remote location, Columbia Point was home to over 8,000 people living in the largest public housing project in New England. High rates of infant mortality and malnutrition marked an area where children rarely, if ever, saw a doctor. Routine medical care was at least several buses and public transit stops away in downtown Boston; emergency care seemed even longer. It was an area that even city ambulances did not venture without a police escort.
Dr. Jack Geiger and other health professional established the Columbia Point Health Center and began a revolution in the way doctors and nurses provided care.
Routine medical care was at least several buses and public transit stops away in downtown Boston; emergency care seemed even longer. It was an area that even city ambulances did not venture without a police escort. Located inside the public housing project basement, the health center offered routine primary care to families living in the neighborhood, regardless of anyone’s ability to pay. Dr. Geiger and his colleagues believed in a direct and reciprocal relationship between poverty and health. In an interview with Time Magazine in 1968, Dr. Geiger explains, “We have known for a long time about the relationships between poverty and health without fully facing up to them. The poor are likelier to be sick. The sick are likelier to be poor. Without intervention, the poor get sicker and the sicker get poorer.” This relationship between poverty and health would be a distinction between community health centers and other sources of outpatient medical care.
As a departure from traditional medical care, doctors and nurses working at community health centers knowingly participated in a larger framework confronting the social, economic, and geographic factors that impact health. Indeed, this first community health center believed that sound medical care would impact more than a neighborhood’s health and truly transform the social and economic conditions where people lived.
This notion that ‘medical care ought to be a right for everyone and not a privilege for a few’ became the bedrock upon which community health centers were built. In what would later be termed the cause of his life, the late Senator Edward M. Kennedy witnessed not only how the lack of medical care gravely impacts a neighborhood but the promising solution of Columbia Point Health Center during a visit in 1966. Years later, Kennedy would describe his visit to Columbia Point, “I have been a strong supporter of community health centers since the inspiring day I visited the one that started it all…” The support of Senator Kennedy, who secured the first federal funding for 30 more health centers, led other community members, mothers, leaders, activists, and professionals to develop health centers in their neighborhoods.
In the immediate years after Columbia Point Health Center was established, it faced multiple fiscal and administrative obstacles. Some of these challenges arose during a transition from a federal grant that provided the sole source of revenue toward formal billing and reimbursement systems with Medicaid, Medicare and other health plans. Healthcare administration itself is complex and changes with the tides of state and federal policy and a web of public and private sector reimbursement mechanisms. In many respects, Columbia Point Health Center, by virtue of being the first fully operational health center, encountered these challenges much earlier than their counterparts and did not benefit from all of the lessons learned we now rely on to administer programs effectively.
Another area of debate was the role of local, direct citizen action and the demands of running a successful health center.
This notion that ‘medical care ought to be a right for everyone and not a privilege for a few’ became the bedrock upon which community health centers were built. Despite a strong, statutory requirement for “meaningful community participation” the health center struggled to maintain enduring, positive relationships with a community-elected governing board which had ill-defined oversight and ambiguous governing responsibilities. Community members rightfully wanted to provide invaluable input on health center operations and this feedback proved central to a community-led health movement. At the same time, the health center faced its own limitations in fulfilling a mission meant to empower local residents and establish non-health related services such as employment readiness and opportunities for advancement. Tension grew from a desire for the community to have a tangible and effective role in the health center alongside the competing demands of administration and operations.
This interplay of apprehension between the professional sector and grassroots community participation was certainly not unique to Columbia Point; those tensions were a natural part of any growing social movement. The community pressures placed on health center administrators and professional clinicians were important efforts that helped change the historically hierarchical medical culture. Despite strained relationships, many strong community leaders emerged and contributed to Columbia Point’s growth and development. It would be impossible to know how community health centers would have developed without the statutory requirement for meaningful community involvement, but the notion of patients and residents participating in the governance of their community health centers was at once novel and essential – and ultimately a distinctive quality that remains in place nearly 40 years later.
Amid these dynamics, Columbia Point Health Center had four agency hosts, acting as a fiscal conduit, in 20 years: Tufts Medical School (the founding agency), Boston Department of Health and Hospitals, Action for Boston Community Development Inc. (ABCD, the local anti-poverty agency) and a local non-profit formed to run the center, Peninsula Health Committee. Not surprisingly, Columbia Point suffered under the governing instability and problematic management, bringing the health center within moments of closing its doors several times. A staff member at that time recalls feeling the day-to-day insecurity of whether the health center would remain open. Finally, in December 1984 staff received pink slips in their mailboxes and the first health center in the country was set to close. Yet, before learning the fate of Columbia Point Health Center, we must first travel a few miles away to Neponset Health Center.
Neponset Health Center, 1971-Present
During the mid 1970s in Dorchester, Massachusetts, a few mothers sat around a kitchen table and talked about the lack of medical care for their children. They were not interested in social movements or wide-scale community activism; these mothers simply wanted doctors in their neighborhood to care for their families. Unlike other neighborhoods in urban Boston, the Neponset area of Dorchester did not face alarmingly high rates of unemployment, distress, and disease. It was a largely tight-knit Catholic Irish-American and Irish immigrant working-class neighborhood located near the waterfront, not far from the center of downtown Boston.
What this area lacked, however, were medical providers. An analysis from the early 1970s found that the number of primary care doctors in Dorchester – home to over 22,000 people – was well below the average for downtown Boston and for the nation. At the same time, Neponset had another unique characteristic: the average number of children in Neponset families was much higher than the national average. While the Neponset community had a larger than average need for pediatric and primary care, few doctors practiced nearby. Like many neighborhoods lacking sufficient primary care, over 30% of families in Neponset relied on the emergency department at nearby Carney Hospital as their routine source of care.
This overreliance on care at an emergency department struck the women living in Neponset as a problem they should set out to fix. Local residents and the women around that kitchen table were well aware of the health and social problems affecting other neighborhoods in Boston and did not want their community’s health to deteriorate because of insufficient access to doctors. These women initiated a process involving other residents in Neponset and healthcare administrators to address the shortage of doctors culminating in the creation of the Neponset Health Center. The need for and initial success of the health center was immediately evident. In January 1971, the first month Neponset Health Center was open, physicians treated over 120 patients. A year later, the health center provided over 11,000 visits. By 1984, Neponset Health Center continued to grow; meanwhile, nearby Columbia Point Health Center, faltering under the weight of administrative crises, fell into legal receivership.
In December 1984, Daniel J. Driscoll, Administrator at Neponset Health Center, received a call that Columbia Point Health Center was about to close and needed help.
This overreliance on care at an emergency department struck the women living in Neponset as a problem they should set out to fix.Dan had great respect for the first health center in the country and did not want the legacy and historical significance of Columbia Point to fade out quietly because of administrative and operational troubles. During that time, Neponset Health Center was formally approached about taking the reins of Columbia Point Health Center. One of the conditions imposed by the federal funding agency was that Columbia Point needed to find a fiscal sponsor that was also a federally funded 330 health center. A plausible and likely partner could be Neponset Health Center – geographically close to Columbia Point but a world away in the segregated Boston of the 1970s and early 1980s.
Those unfamiliar with the racial dynamics of that ugly time in Boston’s history perhaps might not understand why the option to merge Columbia Point Health Center and the Neponset Health Center was a formidable proposal. Racial violence and resistance to desegregation lasted well into the 1970s among African-American and Irish-American communities living largely in separate sections throughout Boston. Despite being bordering neighborhoods and peers in the community health center movement, the decision to unite the Neponset Health Center – a largely Irish-American community with the predominately African-American and Latino community living in Columbia Point – was radical.
Dan Driscoll approached the Board of Directors at Neponset Health Center and initiated a lengthy discussion about the prospect of merging the two health centers. Some of the discussion involved logistical considerations of Columbia Point Health Center and the administrative changes that would be required for it to regain solvency. Other considerations focused on a thoughtful examination of the combining of two very different neighborhoods in a time where the scars of segregation and parochialism had not yet healed, nor were they forgotten. Moreover, there was no roadmap for this type of decision as health centers, at that time, focused rather exclusively on a given community or target area.
Harbor Health Services, 1985-Present
Despite some initial reservations, the Neponset Health Center’s Board of Directors unanimously granted Dan’s request to explore a formal relationship with Columbia Point Health Center.
It is fitting then that Harbor Health Services would be defined by an unwavering sense of social responsibility, an entrepreneurial spirit, and a steadfast commitment to its mission. The two Boards of Directors combined and Harbor Health Services, Inc. was born, shepherding the first health center in the nation into a 24-year span of stability and re-invigoration. To this day, the health center remains on Columbia Point. In 1990, the health center broke ground for a new facility and moved out of the housing project and into a full standing clinic. This was an opportunity to honor its founders and Columbia Point Health Center was renamed the Geiger Gibson Community Health Center; both founders attended the ground-breaking ceremony which fittingly took place alongside the center’s 25th anniversary. As perhaps the definitive realization of the community health center mission, many of the families from Columbia Point have moved on to have healthy, dynamic lives and return to the Geiger Gibson Community Health Center with their children and grandchildren to continue their care.
It is fitting then that Harbor Health Services would be defined by an unwavering sense of social responsibility, an entrepreneurial spirit, and a steadfast commitment to its mission. Community health centers were by definition located in a targeted area and yet Harbor Health brought two very different communities together in a shared undertaking, and it would not be the only time.
In another example of expanding the notion of what a community health center is, Harbor Health responded to a critical need for access to dental services in much the same way it responded to other health crises decades ago. There was, and still is, a stark need for dental care on Cape Cod. The lack of fluoridated water and a severely inadequate supply of dentists serving low-income people have resulted in overwhelming oral health disease and decay. In fact, dental disease is a leading chronic health condition among people living on Cape Cod. In the 1990s, one dentist reflected that low-income and working class families, unable to afford routine dental care, experienced tremendous problems and described the prevalence of dental disease as commensurate with conditions in lesser developed countries.
Ellen Jones Dental Center, 2000- Present
The Lower Outer Cape Community Coalition had been trying to address the shortage of dentists through community organizing and sought to establish a dental clinic for low-income individuals and families. These local groups approached Harbor Health for help addressing the pervasive oral health problems affecting communities on Cape Cod. The Coalition made tremendous grounds securing the public support needed behind any successful attempt at starting at health center. Yet they recognized they lacked the administrative and operational expertise to operate a health center and secure much needed federal funding to grow a large enough health center to meet the demand.
Activists engaged Harbor Health to leverage its decades of experience administering health programs. A staff member working at Geiger Gibson Community Health Center, who lived on Cape Cod, liaised between the activists and Harbor Health to explore an opportunity for collaboration. Partnered with the local community, Harbor Health obtained the support of Massachusetts Departments of Medical Assistance and Public Health and opened a community dental center in Harwich, Cape Cod. This center was named in honor of a local oral health advocate, Ellen Jones. In this instance, the local activists recognized the need for administrative and operational experience to get a dental center up and running, and Harbor Health recognized that only local residents familiar with their community could establish crucial buy-in from key stakeholders.
Mid Upper Cape Community Health Center, 2003- Present
Shortly after establishing the Ellen Jones Dental Center, another community group on Cape Cod approached Harbor Health about starting a full service health center in Hyannis. Local advocates had embarked on a tremendous amount of ground work convincing skeptical residents the value of health centers but they acknowledged the difficulty in obtaining federal funding to ensure a sufficiently resourced center. In 2003, the original organizers of the Mid Upper Cape Community Health Center voted to join Harbor Health in order to improve their funding opportunities and also leverage Harbor Health’s decades of management expertise.
A major priority established from the decades-earlier merger of Neponset Health Center and Columbia Point was to ensure that Harbor Health truly understood and appreciated the needs of Cape Cod residents. It was not an option to simply operate a health center without embracing and absorbing the unique culture of Cape Cod. True to the mission of community health centers, Harbor Health invited Cape residents to serve on the Board of Directors and play an integral role in ensuring Cape-related priorities in future planning.
Both of these instances illustrate a theme in the Harbor Health story: expanding the notion of a traditional health center to bring different communities together in a shared vision of providing widespread access to medical, dental, behavioral health, and social services, regardless of ability to pay. As was the case with Columbia Point, the decision to operate health programs on Cape Cod was a somewhat risky endeavor considering the cultural differences between Boston and the Cape. But the public health data documenting the severe dental disease and residents’ expressed desire for oral health services was enough to convince Harbor Health that they had an obligation to confront these challenges.
Harbor Health Services 2010 and beyond
In our 45 years, Harbor Health responded to calls for action, redefining the health center movement and growing into a national healthcare leader<
It was not an option to simply operate a health center without embracing and absorbing the unique culture of Cape Cod. The past four decades have brought tremendous changes from the growing Vietnamese community in Neponset to the large Brazilian community on Cape Cod and at each step Harbor Health adapts quickly to emerging communities needs. Harbor Health employs medical interpreters and the latest technology to communicate with patients in 170 languages and dialects and has invested time, energy and critical financial resources to implement Electronic Medical Record (EMR) and Electronic Practice Management (EPM) at each of its 4 health centers. These technological innovations enable Harbor Health the ability to streamline clinical communication and operations across multiple departments and sites. These advancements have contributed to the consistently high quality medical care Harbor Health provides while preparing it for future innovations. In 2012, Harbor Health received the HRSA Capital Development Building Capacity Grant, a fund that is awarded to health centers that provide medical services to underserved communities. With the grant, Harbor Community Health Center-Hyannis (formerly Mid-Upper Cape Community Health Center) will move to a bigger facility to help accommadate the amount of patients seen at this location.