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Spring 2004
photo by Rose Lincoln  
Caring for the Community
Charlene Galarneau on giving communities an effective voice in health-care decision making.

Nearly 30 years ago, Tufts quietly began Community Health, the first interdisciplinary effort on campus. It proved a small but attractive program of study for students intrigued by the complex intersection of healthcare, medicine, and social and ethical issues. In recent years, as these issues have gathered wider momentum, so has the program; two years ago, it officially became a second major. Charlene Galarneau, lecturer in Community Health, is pleased to observe this groundswell of interest in a field that has allowed her to work on issues such as the ethics of public health and healthcare, religion and medicine, and women and health. Galarneau met with Laura Ferguson to talk about community health and healthcare and why they deserve more serious reckoning in national discussions.

Q What drew you to this field?
A I started working in community and migrant farm worker healthcare services in the late 1970s in Colorado, with rural, largely Latino populations. I was a health educator and then an administrator at the local and state levels. I realized that I could spend my life at a one-clinic system. It was important work, it needed to be done. But I became very curious about why things were the way they were. Why did we have a healthcare system that did not serve the needs of many? The lines out the clinic doors persisted, no matter how hard we worked.

Although this was a large primary-care clinic system, we experienced a lot of challenges getting people the care they needed. Local institutions had sliding fee scales based on ability to pay, but that made us reliant on public monies, especially federal funding. I became interested in the way decision makers acted on behalf of underserved people. I wanted to know more, both about the ethics—what made individuals and groups make certain decisions—and about how our healthcare system got to where it was and how we might change it. That sent me back to graduate school, to study religion, because I was interested in religious ethics as well as philosophical ethics. I earned a master’s degree and then came to Harvard, where I earned a Ph.D. in religion, again, specifically focusing on the intersection of ethics and health policy. I was always blending the two.

Q How do you define community health?
A Very often people think of community health in fairly narrow terms. They think of it as public health—the health services the government provides at the federal, state, and local levels. In community health, we expand that notion to include all groups involved in health and healthcare—nonprofit organizations, advocacy associations, and communities themselves. And by communities, I mean local communities and all the communities that comprise the local community—cultural, professional, and religious, for instance. These communities are home to the physical and social environments that create health, home to our varied understandings of health and healthcare, home to most of our healthcare, and home to many benefits derived from health and healthcare.

Q What’s driving that broader social framework?
A One force is people’s frustration with a system that does not respond to them the way they need in order for them to be healthy, not just as individuals but as community members. In the public health arena, we’re very comfortable with addressing the physical environment—clean air, clean water, regulation of food establishments, non-smoking restaurants. But we also need to address the social environment. We need to understand health in relational terms: What kinds of relationships do we have within and among our communities? How much violence is there? Discrimination? Poverty? How do we treat one another? Do we “care” for one another, as in, provide care for one another? We now know that these relationships contribute to our health as individuals and as a community.

We certainly have put the bulk of this country’s healthcare resources into a highly technical, medicalized, acute care–oriented system. But when you compare us as a nation to other industrialized countries, our health status statistics aren’t good. Relative to the healthcare structures of many other countries, the U.S. system is extensive. So we need to look for other explanations for our declining health status.

Q Do we need our political leaders to bring attention to this gap?
A Oh, absolutely. We have 44 million people who are uninsured. About twice that many are underinsured. We need a national conversation about community health that will take a bigger, broader look: What does it mean to care? What would it mean to be a healthy United States? Somerville or Medford? Moreover, what would it mean to have a just healthcare system? We need to bring together all interested parties in determining that. I think it is a matter of social justice. It is not just who gets the insurance card, but who decides what you get with that insurance card. It shouldn’t only be elected officials, physicians, and managed care administrators. It should also be the very people who are going to be cared for and paying for those services.

Q You feel that local communities have a moral responsibility to provide care for their members. Why?
A Healthcare is in large measure a community good. People often feel a stronger sense of responsibility to people who live on their street or in their town than they do to those three states over or 3,000 miles away on the other coast. And, usually, healthcare is a local event. Unless you have a particularly serious condition and financial resources, you aren’t going to travel far to get care. People choose primary-care providers geographically close to them. Also implicit in healthcare-reform discussions are particular values about who should pay, who’s responsible. I just finished a health ethics and policy course in the fall where we talked about what responsibility you have to others regarding healthcare. Should your health insurance only cover what you need, or are you willing to share the financial risk with others? It’s very interesting that insurance, when it started in this country, was often a cooperative mutual aid endeavor. People kicked into a pool of money, risking that they might not “use” their monthly premium. But if they ended up in the hospital, then that care would be paid for. Increasingly, insurance in this country has become experience rated, where our premiums reflect our individual risk. So what is our responsibility to care for others? That question needs to be asked not just at the national level, but within communities themselves.

Q Are you optimistic about change?
A Most local communities already understand that they have a responsibility to public health. They do immunizations, well-baby clinics, sexually transmitted disease clinics—conventional public health programs. But clearly community healthcare must be integrated with public health. I am hopeful. I am now looking at Canada, where the national government sets certain standards and provides some funding, but where the provinces have primary authority for healthcare and public health. Nine of the ten provinces in Canada have now shifted some of their responsibility to district health boards, where community members are making decisions about how their resources will be spent.

Q Ultimately, it seems that looking at things at a community level is not a conventional approach. In many ways, it’s radical and innovative.
A Exactly. But the students in Community Health tend to be pioneers in spirit; they see the reality and the value of taking a community perspective. The future of a just healthcare system in this country relies in part on recognizing multiple communities and the roles they play in health and healthcare. Our challenge now is to recognize this diversity at the local level and to give those communities an effective voice in healthcare decision making.