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The Surprising Rural Health-Care Legacy of the ’60s

A country road with "Good Health" written on it in block letters
Gustavo Frazao via Shutterstock

Of the many challenges for America’s rural communities, near the top of the list is access to health care. Rural clinics and hospitals are closing across the nation. When they close, it’s hard for younger families, and older residents, to stay in town—and harder to attract new businesses, or attract replacements for the doctors, nurses, and other health-care workers who may be retiring from their practices or just leaving town.

Previously we’ve reported on the realities of smaller-town and rural health care in Brownsville, Texas, and Ajo, Arizona. This is a report from the smallest city we have visited in our travels, in spectacularly beautiful though remote far Down East Maine.


Today’s health care in Eastport, Maine, traces its roots back to Lyndon Johnson’s War on Poverty and the establishment of the Office of Economic Opportunity (OEO). In this, it is like a large number of other small communities across the country. Just as today’s libraries bear the century-old imprint of Andrew Carnegie, and many of today’s post offices and other public buildings are legacies of construction and mural-painting efforts launched during the Great Depression by Franklin D. Roosevelt, today’s remaining rural clinics are, in many cases, the effects of an initiative launched 50 years ago. Along with other OEO initiatives, such as Job Corps, VISTA, and Head Start, that remain to this day, this rural-health initiative has shaped the primary health care in poor or underserved areas long since it was started.

Back in the 1960s, enter a young medical doctor and civil-rights activist with a vision. This was H. Jack Geiger, who had spent time in South Africa during medical school and had seen the positive impact that the community health-care model had in the very poor area of Pholela. Later, back in the United States, he spent time in the Mississippi Delta for the Freedom Summer project of 1964 as field coordinator for the Medical Committee for Human Rights.

When he returned to Boston, Geiger connected his observations in South Africa and the Mississippi Delta. Along with a colleague, Count Gibson, Geiger proposed to the OEO to try out what he had learned by starting two experimental, community-based health-care programs, one in Boston’s Columbia Point housing project and the other in the Mississippi Delta. Eventually, these became models for the roughly 1,400 Federally Qualified Health Centers (FQHC) that serve more than 28 million people around the U.S. today.

During our travels for American Futures and Our Towns reporting, my husband, Jim, and I visited two examples of these community-based health centers: Desert Senita Community Health Center in Ajo, Arizona, and the Rowland B. French Medical Center in Eastport, Maine.

Their FQHC designation is a godsend for rural health-care centers. It ensures that the centers will receive, among other things, enhanced reimbursements for patients covered by Medicaid and Medicare, and will offer a sliding scale for those without any coverage. It promises federal malpractice-insurance coverage for providers, extra partnerships for the centers, and more specialist care. Each center is unique in its profile, depending on the community’s needs. For example, the Rowland B. French Medical Center has providers for behavioral health counseling, podiatry, radiology, nephrology, and social support. Desert Senita has a regularly visiting cardiologist and ophthalmologist, a certified Spanish translator, and a special phone line with third-party translators for multiple languages.

The Tides Institute & Museum in Eastport Maine (left) and other historic buildings along Water Street Courtesy of the Tides Institute & Museum of Art

During our travels to towns around the U.S., Jim Fallows and I have come across several artist-in-residence programs, for example in Ajo, Arizona; Eastport, Maine; and Tulsa, Oklahoma. Here is the report from one of those artists, Richelle Gribble, on her experience of being an artist in a new place, how it fits into her practice of art, and how she sees her role in the community.

There is a second perspective of artists-in-residence, and it comes from the communities who host them. Why does a community bring an artist into its life? What do the artists and their presence bring to a town and the people who live there?

For that perspective, I went to Kristin McKinlay, who developed and directs StudioWorks, the artist-in-residence program of the Tides Institute & Museum of Art (TIMA) in Eastport, where Richelle Gribble worked. McKinlay and her husband, Hugh French, founded and run the formidable and influential TIMA, as our colleague John Tierney has written about here.


The inspiration for StudioWorks, McKinlay told me, was that a goal of TIMA was not only preserve history, but to “foster the creation of new work.” And for the town, the goals were equally lofty: to add to the cultural landscape, to bring a new energy, and to help revitalize the downtown. And for the arts: to support the work of artists.

StudioWorks, as renovations finished up (Courtesy of the Tides Institute & Museum of Art)

The artist residency fit with the mission of TIMA, which also includes publications, like this stunning book on Eastport architecture, partnerships with other organizations, letterpress cards, a poster series, and education initiatives.

The Tides Institute launched StudioWorks in 2013. Since then, they have hosted a broadly diverse group of 57 artists from all over the world for stays of two weeks to two months. That number represents a big presence in Eastport, population 1,300. It also represents a big commitment, for 57 artists to travel the 250 miles “downeast” (north and east) from Portland or 115 miles east from Bangor. No one arrives in Eastport accidentally.

Looking out to the Bay of Fundy from the inside of StudioWorks (Courtesy of the Tides Institute & Museum of Art)

The program has grown through hard work and good luck. The Tides Institute bought and renovated a Water Street (the main street) storefront building for StudioWorks. As did many residents and tourists, Jim and I wandered in off the sidewalk early in our first of several visits to Eastport, to see and talk to Richelle at work. Soon, two houses were donated to the program, making for more living and workspace for the artists. Those were within a block of downtown and walkable to just about everything you might really want or need in Eastport. They also bought the old Free Will North Baptist Church, a building large enough to accommodate Undertow, Anna Hepler’s installation, which she describes as  “the hull of an empty ship in … the nave of an empty church,” which we also saw during a visit to Eastport.

Free Will North Baptist church is now an arts workshop and installation space (Courtesy of the Tides Institute & Museum of Art)

The program is funded by foundations, grants, and private funding and provides a $2,000 per month (or prorated) stipend for the artists. Artplace America, a grantfunding organization whose imprint we have seen across the country, was an early supporter, and its impact is akin in a more modest way to Carnegie’s in libraries or the WPA projects in schools, post offices, recreation facilities, parks,  and so on.


The many artists brought many different perspectives to Eastport. Their work and connections have spilled out all over town; in schools, in library workshops, on the pier, along the waterfront, and door-to-door.

McKinlay rattled off descriptions of some of the projects, many of which engaged with the essence of Eastport as a town that is intimate—in every sense of its proximity, history, economy, and culture—with water. Eastport’s placemaking is inseparable from its water.

Here are brief descriptions of some of the work:

Elizabeth Bennett hung drawings off the working fish pier along Water Street, right across the street from StudioWorks. The high tides brought water that erased parts of the drawings as it came in.

Amanda Thackray made paper by hand using the local seawater, and printed on it the shapes of plastic garbage and marine trash that she found while walking along the coastline. Thackray wrote about her residency here.

Amanda Thackray in the print studio (Courtesy of the Tides Institute & Museum of Art)

Montana Simone, whom we met in Eastport last summer when we were there with an HBO film crew, preparing a documentary based on Our Towns, was deftly climbing and scrambling around the ramshackle old pier supports, next to the abandoned sardine canning factory. She wrapped two supports with huge canvases, leaving one in place for what would be two months to be marked and stained by the rising and falling tides.

Montana Simone wrapping canvas at the old pier (Courtesy of the Tides Institute & Museum of Art)

Onya Hogan-Finlay and Kim Kelly hosted an event for the community that included a walk; a picnic with local food shared on a specially-created cloth screen-printed with images of seaweed and other regional flora; and a drawing session on paper letter-pressed with the event title  “Low Tide High Tea.”

The Low Tide High Tea picnic for Eastport residents (Courtesy of the Tides Institute & Museum of Art)

Will Rose made animations about Eastport wildlife, and then followed up later from London for an artist talk with Eastport school kids via Facetime.

Adriane Herman, inspired from her interests in pollution, trash, left and reclaimed items, and her commitment to recycling, worked with found items, such as discarded books and papers. She took her passion into the community in a few ways. She worked with teachers and students at the school on many projects, from zine-making to exploring the local burn pile as a subject for artistic study. She also offered a workshop series at the public library, Peavey Memorial Library, and volunteered at the ultimate local recycler, Eastport’s thrift shop, New to You.

Adriane Herman with Eastport's Shead High School students (Courtesy of the Tides Institute & Museum of Art)

Seliena Coyle undertook a “selfie” project where community members took and developed self-portraits using pinhole cameras and a makeshift darkroom.

Seliena Coyle and the pinhole-camera selfie project on Water St. (Courtesy of the Tides Institute & Museum of Art)

Alicia Eggert took 720 conceptual art photos spanning every single minute of a day from noon to midnight. She knocked on Eastport doors asking to photograph people’s timepieces—from grandfather clocks to microwave clocks to wrist and pocket watches. When Eggert asked for advice on how an artist with such a project might be received at the front doors, McKinlay answered, “The only risk is being invited in for pie.” By the end of the project, people opened their doors with the greeting, “We’ve been waiting for you.” One resident even lent Eggert his watch collection, saying she could fill in some missing minutes that way. McKinlay told me that this wide effort grew into a big wave of good public relations about the artist-in-residence program and contemporary art practice.


McKinlay and I also talked about the economic impact of the program. For those who remain skeptics about the positive economic impact that the arts can have on a town, here are some answers.

In Eastport, three abandoned buildings and a church have been renovated with local contractors and artisans into showpieces. The contractors become their own best marketers, displaying their products for future renovations from businesses and prospective homebuyers in Eastport. The buildings also then require maintenance, landscaping, and lawncare. A local high school student is employed as a year-round intern for the program. A few artists have brought young children with them, and used for-pay childcare in town while they worked. The artists-in-residence become part of Eastport tourism, including the considerable population of artists who live in town and galleries that display their work. The $2,000-per-month artist stipend is largely spent on local commerce.

McKinlay told me a touching story of how the artists can contribute to both the hard economics and the soft cultural spirit of the town.

Tracey Cockrell recording sound, Reversing Falls Pembroke (Courtesy of the Tides Institute & Museum of Art)

Tracey Cockrell, a sculptor-in-residence, was building speakers out of seaweed and electro-conductive thread. She made field recordings around the region with a waterproof microphone. She went next door to the S. L. Wadsworth & Son Chandlery, the hardware store the artists frequent for supplies (and is also one of my favorite Eastport shops; you can find most anything there!), looking for Plasti Dip, a flexible rubber coating to waterproof her microphone. This time, the shop didn’t carry the product, but another shopper, overhearing the conversation, asked what color Cockrell wanted. She said she wasn’t sure yet. The next day, what should Cockrell find on the StudioWork doorstep, but a brown paper bag with the packages of Plasti Dip in every color. The good (and anonymous!) Eastport resident had driven more than 25 miles down the road to Calais and bought them for her.

An aerial photo of downtown Eastport
Downtown Eastport, from above Courtesy of Don Dunbar

The Rowland B. French Medical Center is the primary health-care facility for the residents of Eastport, Maine, a tiny Down East fishing town, population 1,400. Eastport was one of the first of some 50 towns that Jim and visited during our reporting across America for our book, Our Towns. We have returned there a half-dozen times since 2013.

The French Center, along with two others in nearby Calais and Machias, together compose the Eastport Health Center. They operate on a community-based health-care model, which began as part of a rural health initiative from the era of Lyndon Johnson’s War on Poverty to aid the underserved.

When I first learned about the rural health-care centers in Ajo, Arizona, and then Eastport, they struck me as unusually personal and almost quaint in their attention to the local detail of the environment and the people they served. Outwardly, the two couldn’t seem more different, The Desert Senita Community Health Center in a former copper mining town in the middle of the Sonoran Desert, and the the Rowland B. French Medical Center on the powerful tidal waters of the Bay of Fundy.

In another way, the centers shared a foundation that seemed efficient and smart in design and operation. Today, in the horrible and confusing pandemic era, I would tack on a few more adjectives for their model: prescient and exemplary.

The key element is that long before the current emergency, both of them were designated as Federally Qualified Health Centers (FQHC); they are two of roughly 1,400 FQHCs that serve more than 28 million people around the U.S. today. And with this designation, it meant that two of America’s smallest and most remote communities were required to make preparations for a public-health disaster like the one underway now.

As I wrote earlier:

FQHC designation is a godsend for rural health-care centers. It ensures that the centers will receive, among other things, enhanced reimbursements for patients covered by Medicaid and Medicare, and will offer a sliding scale for those without any coverage. It promises federal malpractice-insurance coverage for providers, extra partnerships for the centers, and more specialist care. Each center is unique in its profile, depending on the community’s needs. For example, the Rowland B. French Medical Center has providers for behavioral health counseling, podiatry, radiology, nephrology, and social support. Desert Senita has a regularly visiting cardiologist and ophthalmologist, a certified Spanish translator, and a special phone line with third-party translators for multiple languages.

Being a FQHC comes with requirements and perks. In Ajo, I saw the stacks and stacks of paperwork required of FQHCs by the government to document every step of their compliance with governance, finances, and regulations. I also learned about the one-stop shopping so they could supply services to cover everything from dentistry, x-rays, pharmacy, translation services, rotating visits from specialists, and emergency preparedness. At the time, Jane Canon in the Ajo center described that emergency preparedness meant “self-ready” for everything from a massive power outage to an ebola outbreak. At the time, we both chuckled at “ebola outbreak.” That doesn’t sound funny anymore.


I spoke by phone last Sunday morning with Ellen Krajewski, the director and CEO of the Eastport Health Center, to learn how emergency preparedness in Eastport has played out so far.

We started with a few weeks ago, when it was business as usual at Eastport’s Health Center. People were coming in for their primary-care appointments, drop-ins, the usual. Then came the identification by the CDC of the coronavirus as a pandemic. As an FQHC, said Krajewski, echoing my conversation in Ajo, we are required to have emergency preparedness plans. “So,” she said, “we had a pandemic plan.” The trigger was pulled and Eastport immediately kicked into gear to engage the protocols and adhere to guidelines from the feds and the states for pandemic operations.  

Here’s what the plan looks like and here’s how it has worked in reality:

The pivots: The health center shifted from being an all-purpose primary care provider to accepting only acute visits in person and providing all other visits remotely, either by phone or virtually. It was tricky: While operations were clear to those inside the building, not all the residents in Eastport were aware of the news and, understandably, what that would mean to their usual healthcare behaviors. As now throughout the rest of the country, word needed to get around Eastport that the first step was not showing up at the center, but calling on the phone.  

The center set up a series of questions by phone to determine how best to provide needed care, from those with what appeared to be illness unrelated to coronavirus to triaging patients with what may be coronavirus symptoms. The very sickest people go to the hospitals; the middle group may come to the center; the least sick generally stay at home.

Some of both the regular patients and the potential COVID-19 positive patients needed to be seen in person, so the center set up work-arounds for organizing their physical space. They scoured the possibilities and came up with separate locations for seeing potentially COVID-19-positive patients and regular patients. They flipped a board room into a sterile room, with a trained nurse to administer COVID-19 tests. Krajewski told me that the center has a limited supply of tests, and they follow the CDC guidelines on who is eligible to be tested.

Within 10 days, all the providers were trained and using remote technologies. “It meant a huge, gigantic change,” Krajewski said. But it was one they were generally equipped to do, despite their relatively-older, less tech-savvy provider population. Being a FQHC, the center was already heavily teched-up, and familiar with using the technology required to comply with all the usual FQHC reporting and protocols.

On the patient end, it was more complicated. Eastport is a rural, remote area, where broadband coverage is spotty, and the population is less likely than much of the U.S. to be able to afford computers and internet subscriptions. Compounding the problems, Washington County—where Eastport is located—has one of the oldest populations in Maine, a state that has the oldest population of any in the country—meaning overall comfort with technology is rarer than usual.

The equipment and testing: As of our last conversation, Eastport has an adequate, though limited, number of test kits; more have been promised. Test results have been slow in coming, but the speed is improving. They have not yet recorded a single positive test for COVID-19. Maine has promised some community testing sites around the state, but tiny Eastport won’t be one of them. Those will be located in a more populated area, far away from Eastport.

Their original supply of equipment has sufficed. There are enough PPEs and masks, although the center has already back-ordered and duplicate-ordered, just in case. Eastport doesn’t have an ICU or a ventilator. The nearest so-equipped hospitals are in Machias and Calais, which are 60 and 30 minutes away, respectively.

The staff: During our travels, we frequently heard about rural America’s challenge to entice new young staff into professional positions like doctors, nurses, dentists, and teachers. In fact, Eastport, in another farsighted effort, has already set up scholarships for high-school students pursuing medical professions, hopefully giving them a reason to stay and practice in their hometown.

Today, the staff and providers at the center are generally older and are more likely to have comorbidity issues that come with age. The pandemic presents a new challenge to this provider base, where they naturally fear their constant exposure and feel more personally vulnerable.

The finances: Finances for the center and payments for services are complicated now. On one hand, there has been some easing on federal rules and regulations for payments and coverage, making the system work more smoothly. On the other hand, fewer patients are coming to the clinic. Patients are reluctant to show up, and they are delaying their well visits. When Krajewski and I talked, the center’s roughly 150 visits per day had dropped to 22. Already 12 employees in the three centers of the Eastport Health Center network have been furloughed, and five others are working reduced hours. And while virtual visits are increasing, they are not replacing in-person visits either in number or revenue.

The culture: For all of us, the specter of COVID-19’s arrival into our communities is scary and looming and bizarre. For all of us, there is a sense of unreality—until it becomes real—that maybe it won’t get here, maybe we can be immune from this tragedy. Because part of the cultural appeal of living in remote towns like Eastport and Ajo is being a good arm’s length away from national issues or intrusions, it makes sense that this instinct or temptation of “not me/not us” could be even stronger. It is a familiar and attractive idea that the virus will remain far away, like some other 21st century disasters.

We will stay in touch with our friends in Ajo and Eastport to see what their futures hold.

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