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
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.