While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
Position: Medical Director, Community Health Services
He is called doctor, preacher, historian, motivator, confidant, counselor and friend. He mentors young men to go to college, lectures within the community on topics from Alzheimer's disease to 'History of Blacks in Education in Fremont City Schools,' reads to children, visits the elderly, has sign language skills....He provides health care to the community of Fremont and has provided health services to the people of Honduras and Liberia.—Viola Gomez, Health Administrator, Rural Opportunities
Dr. Jackson is a leader and a kind, sincere individual who is committed to helping his fellow man and improving his community....I have witnessed first-hand how he has motivated others to change their personal attitudes and succeed. He does this as a modest man, always passing the credit to others.—Mayor Terry M. Overmyer, Fremont, Ohio
He cares about what happens to people, especially young people. He always has a kind word, and never anything negative to say about anyone. Whenever you see Dr. Jackson, he always has a smile and a compliment for you.—Client, Community Health Services
Alvin Jackson was just a baby in the winter of 1951 when his mother leaned too close to the fireplace in the family's farmhouse in Portal, Ga., and her housecoat caught fire. She died six hours later—but not before arranging for her parents to take care of the baby.
She knew that her husband—a migrant farm worker who "followed the seasons"—would be away for months at a time. So Jackson was brought up by his grandparents, an aunt and uncle, and his father when he was around. Ironically, the tragedy of his mother's death led to his being raised in a more stable environment, where education was stressed.
Just as importantly, there was a village to raise this child. Portal was a town of about 500 that offered a rich community life. Most of the residents were descendants of former slaves who, after the Civil War, bonded together to found their own town. They looked after their own health matters, and looked after each other.
His grandmother often sent Jackson to sick people's bedsides to spend the night, keep them company and alert adults to any emergencies. Jackson remembers being severely frightened by the wheezing of an asthmatic elderly cousin one night. Nevertheless, it was these early experiences helping the sick that played strongly into his later decision to become a doctor to the poor.
Jackson attended the Willow Hill School in Portal, a three-room institution built by the community's founders, who saw the importance of education in bettering their lives. (In 2005, Jackson was part of a group of Willow Hill alumni who raised funds to save the school from the auction block. The group intends to make the place a heritage museum, "to bring a sense of pride for our ancestors who, with very limited means and with limited background, were able to do so much with so little.")
When he was old enough, Jackson joined his father for summers in the fields, picking crops. It was backbreaking work, and it gave him a deep respect for all those who labor under harsh conditions, for low pay and few benefits, to put inexpensive food on our tables.
In the 1960s, Jackson was one of a dozen African-American students to integrate all-white Statesboro High School. As a teenager on the front lines of the civil rights struggle, he was subjected to taunts and threats. His grandparents feared for his safety and their own. Jackson, however, was not afraid. He felt he was on a mission. He believed in that mission with his whole heart, and was determined to stand up and take whatever came at him.
On one occasion, a group of white students tried to run him down in their car after school. It was not the first time. On previous occasions, he'd had to jump into a ditch to avoid getting hit. This time, however, he'd had enough. "I took this large stone and I hurled it right into the side of the door...and it bent the door. And then they said—oh, they used the n-word—'Oh boy, we're gonna get you today'... The next few days they would be at school, they tried to intimidate you. But I was never, in all honesty, afraid...I would stand up to a whole group. I had this philosophy that 'if I get one of you, then that's all I need.'"
One of his teachers, assuming that he was headed for a life in the fields like that of his father, suggested he take agriculture courses instead of the more difficult ones, like biology and Spanish, that were for college-bound boys. Jackson didn't listen. He made the school's honor society and, after graduation, enrolled at Oakwood College in Alabama. He received an academic scholarship his second year there.
At the urging of the school's president, who had become a mentor figure, he applied for—and won—a nationwide scholarship to spend his junior year at Keele University in England. He remembers that Europeans "were always eager to ask me what it was like to be an African-American. In America, I had never gotten involved in these kind of discussions. So it created an insatiable urge for reading and discovery and travel."
On school breaks, he took the opportunity to fulfill a childhood dream and travel through Europe. "After seeing Moscow, Leningrad, Paris, London, Edinburgh, Berlin, Rome—and all those great cities—I thought, 'Oh my God. All of our people back in America really do not have a good vision of what the world is really like.'"
"One of the things I always try to instill in people is that...no matter what situation you find yourself in, there is an opportunity. And if you have an opportunity and you see it, do not miss it. Because you may not ever travel this road again."
Returning to the United States, Jackson transferred to Oakwood's sister school, Andrews University in Michigan, which offered a program in marine biology, and graduated with a B.S. in biology. But he did not end his education there. After spending a summer at a marine biology research station in Puget Sound, he enrolled in the Ph.D. program at Ohio State University, studying medical microbiology and infectious diseases. It was at Ohio State that Jackson met his future wife, Gayle, who was getting her Ph.D. in pharmacology. The two married while still in graduate school and went on to have four children-two are doctors, one a banker, the fourth still in college in 2006.
To earn money, Jackson worked as a part-time lab instructor for Ohio State's medical students. Soon, he began to wish he were one of them. "I became hungry for it," he remembers. "I just realized that I wanted to be with people, and work with people, and help people." He took some additional courses, then transferred to Ohio State's medical school. Throughout his years as a medical student and resident, his wife supported them by working as an adjunct instructor in Ohio State's Department of Pharmacology and as an editor at the American Chemical Society.
During Jackson's four-year family practice residency (at Mercy Hospital in Toledo, Ohio), one of the places he was posted was in nearby Fremont. It was a small neighborhood clinic called Community Health Services. Fremont is a diverse community, including many African Americans and—in season—migrant farm workers. Community Health Services provided primary health care to residents of three rural counties, and was also the only federally funded health provider for Ohio's migrant farm workers.
The moment Jackson walked through the doors, he knew he'd found his proper place in the world. As he puts it, "working at a community health center, working in this community, was the coming together of a lot of who I was as a person."
Unlike the migrants he'd known in the Southeast, these were almost all Spanish-speaking. Luckily, having ignored his high school teacher's advice, Jackson was fairly fluent in Spanish. "Years later," he says with a smile, "she told me I was one of the best Spanish students she ever had."
Jackson loved Fremont's diversity and its rural character, which reminded him of his childhood days. Offered a job as staff physician at Community Health Services on completion of his residency, Jackson jumped at the chance. His wife, after some convincing, supported the move. Since it meant she would have to give up both her jobs, the couple agreed that once he began to bring in enough money, she would shift gears and devote herself to volunteer efforts. Their young children were unhappy about moving at first. But once they saw the house Jackson had bought for them—what used to be the mayor's house, right across the street from his clinic—they were enthusiastic about the move.
Jackson soon developed a reputation as a physician who treated everyone equally, regardless of social standing, status or ability to pay. In 1995, he became the clinic's medical director. Overcoming initial resistance, he moved the clinic toward a more holistic approach, implementing the chronic disease model of health care, in which patients are full partners in their own treatment course and health maintenance.
When the family first moved to Fremont, Jackson's wife Gayle went to work as a case manager for an organization called Treatment Alternatives to Street Crime. Once her husband was able to support the family on his own, she quit her job and devoted herself to running a new organization the couple founded, the African-American College Club, to tutor students of color and encourage them to go to college.
Every year since the club's inception in 1995, the Jacksons have rented a bus and taken students on a tour of several colleges, teaching vital life lessons along the way. "We both strongly believe that education is the great equalizer," he says. The program has since expanded to reach more and younger students. Many alumni credit the club with showing them the way to a brighter future.
Also in 1995, Jackson helped found Brother to Brother, a mentoring group for young African-American males to help steer them away from guns, drugs and alcohol. In tandem with College Club, the two groups provided a powerful tool for young people to achieve positive outcomes. "We believe that everyone is a leader...that everyone has leadership abilities," he says. "Some need to be taught more than others how to best use them."
When Jackson arrived in 1993, Community Health Services offered evening hours twice a week. This was because farm workers, especially migrants, were often unable to make daytime appointments. Even with the evening hours, it gradually became apparent to Jackson that for many reasons—including inadequate means of transportation, language difficulties, and fear of deportation—migrant workers were not making adequate use of the clinic's medical and dental services.
By the time they came in for treatment, many were already very sick. "Health care was not the first thing on their agenda," Jackson explains. Over time, he and his team realized that, to do more primary prevention and more holistic health, they would have to take their clinic to the fields.
Together with two nurses and translators (for the nurses, not for him), Jackson rode out into the fields for the first time in the summer of 1998. He and his colleagues brought a couple of vans, a folding table, a dozen or so chairs, some large containers to hold medicines—"What we called our pharmacy," he jokes—and some small, refrigerated containers to keep immunizations fresh. "Well, quite naturally, we got quite popular because care was accessible. It was right there."
The working and living conditions of the migrants were a shock to those who accompanied him, though not to Jackson. "There are still outdoor toilets...rudimentary structures that multiple people live in...poor sanitation. There's still a problem with trash pick-up and delivery. And also the...pesticide exposure that a lot of the children still have to deal with." It was no wonder many of them suffered from major, untreated health problems like tuberculosis, hypertension, asthma, diabetes and the toxic effects of pesticide exposure.
"And then the larger issue," Jackson laments, "which is really painful for me, is the lot of the youth who should be in school, who are still working in fields, because...migrants don't always come under the jurisdiction of the laws that affect most of our kids.
"Bear in mind that the migrant program is part of the vegetable and food industry in America, which is an $18 billion industry. And that industry has to be fueled by between 3 and 5 million migrants who move around America. And most people in America have no concept of this....When you eat that tomato, that lettuce, that cucumber, you have to realize the sacrifice that someone made to get that to your table."
Eventually, Community Health Services was able to free up some federal funding to purchase a fully equipped mobile health unit. This setup enabled a broader range of in-the-field services (including a medical and a dental operatory), greater privacy and much greater reach—expanding to a 12-county area from the original three counties. The mobile unit has proved extremely versatile, doing recent duty at local schools as an immunization center, and in Mississippi, assisting victims of Hurricane Katrina.
"As I traveled, the smell, the flies, the heat, all came together to create an image of desolation and destruction and despair," says Jackson of his time in Bay St. Louis, Miss. "As you talked to the people who went through this, you could feel and touch their anguish. But deep inside all of that you could feel the survival of the American spirit...I felt reassured that we are going to get redevelopment, we are going to come back." Nevertheless, he was profoundly disturbed by the lack of preparation and organization of those who came down to help. "I realized how much work we needed to do as a nation."
Unlike most physicians, Jackson has always involved himself in his patients' lives beyond their connection in the examining room. "I visit them in the hospital. I do home visits. I work with the kids," he explains. He also goes to wakes, because "I learned long ago what they used to tell us in the South, at Willow Hill—you really know who cares about you when there's death in the family." He also began speaking out locally, giving talks on health issues and on topics of importance to the African-American community.
His efforts also went beyond his immediate area, when he lobbied the U.S. Congress to maintain funding for community health centers so that they could continue to recruit providers to serve in under-served areas. In March 1999, Jackson joined a medical team going to Honduras to help with relief efforts after Hurricane Mitch devastated that country. And in 2002, he provided health services to the people of Liberia, under the auspices of Africa House, to help rebuild and restock a hospital that had been gutted by that country's civil war.
Soon, Jackson's outstanding efforts began garnering him state and national attention. In 2000, he won Pfizer's Ohio Quality Care Award. The next year, he won the Department of Health and Human Services' Clinician Award, for outstanding dedication and commitment to the nation's migrant farm workers.
Also in 2001, he won a Robert Wood Johnson Community Health Leadership Award. This honor came with a $95,000 check for Community Health Services, plus a $5,000 stipend for Jackson. Jackson used the money to start a foundation, the Community Health Services Foundation, to support his clinic. The foundation has since raised other moneys it uses to buy pharmaceuticals for migrant workers who cannot otherwise afford them. Jackson not only appreciated the funding, but the chance to get to know the other award winners. "I found that really inspirational," he says, "because it matches a lot of what I believe already...that the individual can make a difference if you get out there."
The award garnered Jackson a lot of publicity, including a feature article in the Cleveland Plain Dealer. This attention in turn resulted in greater contributions to Community Health Services. In fact, the organization has grown quite a bit since 2001. Its patient load has increased, as has its use of electronic patient records.
A new pediatric suite has opened, and Community Health Services has reduced its no-show rate for appointments from 21 percent to 9 percent through patient education. People who did not show for an appointment were required to attend a class where they were informed of the short- and long-term costs of their non-attendance (both to the clinic's efforts and to their own health) and encouraged to keep all future dates. They were then connected with a patient care coordinator who made reminder calls and helped with any barriers to keeping appointments (such as transportation).
Jackson has concentrated on making sure that the health resources in the community—the hospital, the health department and local physicians—use health care in a more collaborative way. He would also like to expand the use of the mobile unit to include home visits to housebound seniors and disabled persons.
RWJF also gave Jackson a grant of $15,000 in 2003, to fund focus group research on the links between education and health among African Americans in the Fremont area. The findings led to the establishment of a new volunteer mentoring program in the Fremont schools.
In May 2004, Jackson was awarded an Honorary Doctorate of Humane Letters from Heidelberg College in Ohio for his humanitarian efforts with the migrant population and assistance in foreign relief efforts.
Jackson and his wife still live in the house across the street from the clinic. "Right here on this corner, this is my own little world," he told the Cleveland Plain Dealer in a 2001 interview. "This is where I work. This is where I live. I can't think of any other place I'd ever want to be...this is my life. My mission. My love."
While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
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