Historically, in times of need, African Americans have relied on themselves and others to meet material and emotional challenges. Through reciprocal sharing, African Americans strategically used resources, harnessed social support, and created deeply woven social networks to mediate needs. This sharing often occurred among kin and friends. This was especially true in caring for children, the elderly, and infirmed or in sharing work responsibilities.1 Reciprocal sharing through these relationships created a paradigm for collectively pooling resources, redressing issues, and supporting well-being. These activities are operationally termed mutual aid.
Since the late 19th century and after, African Americans used the basic functioning of these relationships to provide broader and more complex forms of assistance to community members.2 African Americans through mutual aid shared resources to promote mental, physical, and spiritual well-being. These social arrangements in turn created environments in which "making community" could occur.2
Nowhere are the tenets of mutual aid and making community historically more apparent than in the Black Church. As the oldest institution in African American communities, the church was designed to meet African Americans' needs. As an extension of family and friend networks, churches served as the cornerstone of community life for many African Americans.2,3 Mutual aid societies or self-help groups, which developed from the Black Church, gave rise to pivotal community-based institutions (eg, schools, hospitals).2,3 The Black Church also cultivated leaders, including historical figures like Ida B. Wells-Barnett, Dr Martin Luther King, Jr, and others.4.5
Although the Black Church continues to provide mutual aid for many African Americans, it is not the only institution doing so. African Americans are using mutual aid practices in other domains including politics6 and in redressing health issues.7,8 Mutual aid activities, once provided exclusively by the Black Church, are now undertaken by government agencies, as part of the social welfare system. The shift from community-centered to government-initiated aid, however, is a rather recent phenomenon.
During the early 20th century, government-centered aid (also referred to as hierarchal relief) was viewed with contempt by many Americans, including African Americans.9 Many groups considered government aid a "hand-out" rather than actual support because it did not come from kin or friendship networks. Government-initiated aid came from large, bureaucratic, and formalized institutions, contrary to the informality of mutual aid practiced in many communities. Such aid also came from people whose geography, ethnicity, and income, in general, varied greatly from those of its recipients. With government aid, commonality between those "giving" and "receiving" mutual aid in local communities was de-emphasized.9 Government aid did meet social needs. But, it did so in ways that were neither mutual nor socially grounded in communities. Nevertheless, greater reliance on government aid did occur during the latter part of the 20th century.
Major social movements in the United States, including the Civil Rights Movement, influenced the passage of more socially directed legislation.9 As a result, the government came to be seen as primarily responsible for redressing unmet social needs. This shift in the government being responsible for social needs was coupled with the rapid inflow of federal money, which dampened many of the community's established practices of mutual aid and self-help.9(p198) More people of color and members of other affected groups (eg, women) also joined the government workforce. Their presence made receiving government aid more palatable to community members. Over time, community members relied less on established social networks and more on government agencies to meet their needs, including healthcare. The Tennessee Office of Minority Health (TOMH) was born out of this history.
Mutual aid's use in the Black Church and the shift to the government meeting African Americans' needs are worthy of note. Relevant also is a closer examination of the common characteristics and underlying principles of mutual aid. These are necessary to understand mutual aid in contemporary practice, especially outside the Black Church. TOMH, a governmental agency, provides a case study for how mutual aid has redressed the health needs of African American communities.
Structure and Function of Mutual Aid
The intents of mutual aid are to support social adaptation, promote coping, and facilitate adjustment to current and emerging situations. This usually happens as a response to economic, political, and/or social pressures (eg, racism, unequal healthcare access).9,10 Mutual aid, although rooted in familial and friendship networks, is not exclusive to them. Larger social groups, reaching across great distances can also use mutual aid (eg, clubs or organizations). Irrespective of its scale, mutual aid nevertheless is connected to interpersonal relationships. People make mutual aid happen. Consequently, mutual aid's structure reflects the personalities and ethos of those involved in it.
Mutual aid's structure is both purposeful and output driven. A group identifies a need. Strategies are developed to redress the need. Aid, in turn, is given and received to meet needs. Within mutual aid systems, there are "identified agents" who give and "targeted groups" who receive. Sometimes these groups are one in the same. TOMH represents most often the identified agent. African American communities in Tennessee represent the targeted group.
Mutual aid's structure also influences its functional operation. Critical to mutual aid's operation are reciprocity (bidirectional sharing of resources), which allows participants to give and receive; reliance on assets; and emphasis on group problem solving. The successful operation of mutual aid is based on a commitment between members to pool and share resources. This commitment can be implicit and informal, on the basis of bonds of familiarity. Or, commitments can be formal ones, established explicitly through contracts, memoranda of understanding, and the like. The TOMH uses both kinds of reciprocal relationships. In each, TOMH works with, for, and on behalf of affected communities of color to improve health processes. In turn, community groups, legislators, researchers, and other stakeholders work individually and collectively with TOMH to do the same.
Mutual aid operates by using the available resources. These resources are commonly referred to as assets. Each member of a mutual aid system possesses assets, whether these are finances, social networks, specialized skills, or political will. When these are all directed toward achieving the same goals, outputs that might not have been possible otherwise can occur. The TOMH has employed this operational strategy in its efforts.
Lastly, mutual aid functions through group problem solving. Critical is identifying issues to be addressed. As a governmental agency, part of the TOMH's role is to inform affected communities about important health issues. Perhaps even more importantly, TOMH's responsibility is to also listen to affected communities. This often happens through public events like community forums. Community forums (eg, focus groups) raise consciousness about relevant health issues for African Americans. During these events, group problem solving takes place between TOMH (as the identified agent) and stakeholders (as the targeted groups). The results are socially transformative because they alter health processes for African Americans in Tennessee. In practice, this group problem solving promotes pride, creates cohesion among members, and empowers participants to believe that they can be social change agents.
Mutual aid, as a practice, emphasizes the principle of self-reliance.9,10 Redressing needs becomes the responsibility of the group rather than of an individual. Identifying needs in this way compels system members to come up with and enact solutions. Assistance from outside sources is appreciated. Nevertheless, the goal for members is to find ways to solve problems themselves. This promotes pride within the group.
Mutual aid also promotes the principle of fraternal-ism.9,10 Mutual aid system members feel connected to each other. These bonds of fraternalism are usually strengthened over time. This often happens because identified agents and recipients are from similar walks of life or share other affinities (eg, ethnicity). By working together, they come to know and trust each other. As Beito describes with mutual aid (also referred to as reciprocal relief), "Today's recipient could be tomorrow's donor."9(p18) Therefore, mutual aid promotes fraternalism by minimizing unequal power relations between group members. TOMH fosters fraternalism by closely working with community members as equal partners. As a result, constituents come to see TOMH as an agency that values their concerns because it identifies with their needs. The remainder of this article will consider how TOMH uses mutual aid to alter processes that support African American health in Tennessee.
Methodology
Data for this case study were obtained from primary and secondary sources. Primary data came from informal interviews and conversations with retired officials of TOMH and Tennessee Department of Health (TDH). Additional primary data were obtained through participant observation by the authors through more than a decade of voluntary and professional contact with TOMH and its activities.
Secondary sources were also utilized. Extant literature dealing with mutual aid and social support systems, especially within the Black Church, was reviewed. TOMH reports and other documents about minority health in Tennessee were also used. Program brochures, evaluation reports, relevant epidemiological data, and other published information lastly served as additional secondary data sources for this case study.
TOMH: A Brief History
In the 1980s, the discrepancy in health status between minorities and White populations became a national priority. In its landmark report in 1985, the Heckler Commission said that there was continuing disparity in the burden of death and illness experienced by African Americans and other minority Americans as compared with that experienced by the nation's population as a whole.11 The report further indicated that such disparities had existed because accurate federal record keeping began more than a generation ago. Although health charts itemized steady gains in the health status of minority Americans, stubborn disparities remained--an affront to both the nation's ideals and technological innovations in American medicine.11
Such health disparities, which were known for years in minority communities, finally gained national attention eventually leading to concerted public health efforts at the state and national levels. Many of these focused on African American health concerns. Leading the way to eliminate health disparities, the US Department of Health and Human Services created the Federal Office of Minority Health (FOMH) in 1985.12 FOMH's mission is to effectively redress historical disparities by developing policy, providing critical health information, funding, and providing technical assistance to state minority health entities and local community-based organizations to improve the health status of minority populations.13
The State of Tennessee did not formally respond to minority health disparities until almost a decade later. In 1994, leaders from Tennessee minority communities, key legislators, and TDH officials expressed serious concerns about growing gaps in minority health status. In response, the TOMH was established (1994) within TDH to serve as the state's "nexus" for minority health issues. TOMH's establishment served as a watershed moment in Tennessee public health history because it introduced minority health to state government. Since its establishment, TOMH has had three directors, including Stephanie Perry, MD (1994-1995), Robbie M. Jackman, MSSW (1995-2007), and Lesia Walker, MPH (2007-present).
Under the first director, TOMH established its initial goals and objectives (R. Jackman, MSSW, oral communication, June 2007). These would be important to TOMH's mutual aid structure. These goals and objectives identified the common affinities, interests, and purposes, collectively uniting TOMH and targeted groups to support African American health.
During this period, the Minority Health Advisory Council (MHAC) was also convened. A group of minority professionals and citizens from across Tennessee, the MHAC was appointed to guide TOMH and advise the commissioner of health about minority health. This council was preceded by the Black Health Care Taskforce, an ad hoc group of citizens and professionals also concerned about African American health in Tennessee. The taskforce, started in 1990, became MHAC in 1994.
With its second and longest-serving director, TOMH was codified into a state statute in 2004.14 Codification served to secure TOMH's viability beyond a given administration. During this time, TOMH's mutual aid use took shape. Importantly, mutual aid principles including reciprocity, self-reliance, and fraternalism became TOMH's standard operating practice.
TOMH: Mutual Aid in Practice
Fraternalism, defined here as the willingness to be a part of and relate to others was infused into TOMH's practice early on. TOMH started with only two staff members in 1994. Therefore, drawing on others and pooling resources to redress African American health issues in Tennessee was not just visionary, but pragmatic. This too is indicative of mutual aid. It is generated out of a recognized need. One recognized need was that there was too much work to be done and only a few people in TOMH to do the work. This was one challenge; there were others also.
In 1995, there were also limited epidemiological data on African American health in Tennessee. The information that was available pointed to obvious disparities in health outcomes for minorities, especially African Americans (R. Jackman, MSSW, oral communication, June 2007). For example, in 1995, the infant mortality for African American infants was 2.5 times higher than that for White infants in the state (18 per 1000 live births vs 7 per 1000).15 Beyond indicating significant health differences for African Americans in Tennessee, available information gave few definitive answers about where to start redressing these issues. At times the situation seemed overwhelming. Yet, TOMH as a new governmental agency had to do something. So TOMH started with what it had and built on what it knew.
What TOMH had were relationships with African Americans in communities throughout Tennessee. What TOMH knew was that promoting African American health required changing the dynamics of state health processes. In particular, TOMH focused on altering the way health policies were made; improving the quality and availability of data about African American health; increasing access to available health resources; and equalizing the distribution of state health funding. TOMH's work was purposeful. It also required TOMH staff to be persistent in their efforts and remain committed to the common mission of promoting African American health.
By working these social networks over the years and cultivating a common trust, TOMH amassed a network of citizens, researchers, legislators, and others committed to improving African American health in Tennessee. These constituent groups became members of TOMH's mutual aid system on the basis of their common interest. By pooling political, financial, and human resources, TOMH created a mutual aid system whose identified agents and targeted groups were often one and the same. This supported the system's fraternalism.
To sustain the system's momentum, TOMH continually strived to be "out there" in African American communities, hearing what people affected by health disparities were saying. TOMH staff also shared what they knew about African American health. Mutual aid as suggested here was bidirectional. TOMH benefited from information sharing and so did African American communities members. The consciousness of both groups was heightened, thereby making group problem solving possible.
A fundamental issue raised through these ongoing dialogues was the limited presence of African Americans and other minorities in decision making about how federal and state dollars were spent in Tennessee communities. Besides the MHAC, the major community voices in TDH decision making were the state's 95 county and regional Public Health Councils.16 Comprising local leaders in each county, these councils (many of which started in the early 1990s) were responsible for helping the commissioner of health determine local communities' health needs and how funds would be allocated to redress these concerns.16 In many counties and regions, there were few, if any, persons of color on the councils. This pattern persisted throughout the 1990s.
TOMH further promoted self-reliance among African Americans. TOMH sought solutions to African American health challenges by working with African Americans to develop solutions. In 1996, out of these early discussions, several African American community members developed a nonprofit organization called the Tennessee Minority Health and Community Development Coalition, Inc (TMHCDC). TMHCDC operated on a model of group problem solving. It also incorporated principles of mutualism, believing that there was strength in numbers. TMHCDC organized six regional sites (which included coordinators and regular meetings) to represent the interests of African American communities throughout Tennessee. These regional sites covered the entire state including Memphis/West Tennessee, Jackson/Rural West Tennessee, Nashville/Middle Tennessee, Chattanooga/Southeast Tennessee, Knoxville/East Tennessee, and Johnson City/Upper East Tennessee.
The TMHCDC served as the counterpoint to the Public Health Councils. Beyond organizing, TMHCDC implemented activities in local communities specifically geared toward promoting African American health (ie, American Heart Associations' Search Your Heart program). A testament to TMHCDC's self-reliance, it often did this work without state support. Funding from local communities sustained the efforts when no external funding was available. TMHCDC in tandem with TOMH worked to generate outputs that altered the way state public health dollars were used to serve African American communities.
By seeking information, dialoguing with others, and visioning possibilities grounded in African American communities, TOMH pushed a paradigm about African American health that went beyond individual health. Through its mutual aid practices of dealing with health in totality (physical, economic, and social), TOMH stayed close to how people thought and felt. This helped TOMH get African Americans the help needed to support health. Helping African Americans support their health became the hallmark of TOMH's mutual aid.
TOMH's efforts cultivated solid relationships within a diverse social network that included students, legislators, academics, and community members. Leveraging relationships, TOMH strategically planned, conducted research, developed datasets, mobilized political will, and executed activities that were community driven and supported. In turn, TOMH shared what it learned with affected communities as well as state legislators (namely the Tennessee Black Caucus of State Legislators and the Tennessee Black Health Care Commission). By pooling resources and relying on others, TOMH was able to do more with less. Without these cultivated supports, TOMH would not have been able to generate these outputs alone.
The work of TOMH can best be assessed on how it has changed processes within state government and in Tennessee communities that support African American health. Some of these include increasing the number of funded minority community-based service providers; pipelining African American healthcare professionals into public health in Tennessee; encouraging minority researchers and Historically Black Colleges and Universities to examine health disparities; and promoting greater synergy between economic self-reliance and health. The Your Health is in Your Hands (YHYH) project is an example of these changed processes at work.
Your Health Is in Your Hands: An Example of TOMH's Mutual Aid
The YHYH project serves as an example of TOMH's mutual aid. The YHYH project was supported by the FOMH through a state partnership grant to redress health disparities among minority Tennesseans. The duration of the federal support, awarded in 2003, was 1 year.
TOMH recognized that heart disease and stroke were major health disparities among Tennesseans.17,18 In 2003, the age-adjusted mortality for heart disease among African Americans was 365 per 100000 live births versus 262 per 100000 live births for White Tennesseans.17 African Americans were also disproportionately affected by stroke. The age-adjusted mortality for stroke among African Americans was 89 per 100000 live births versus 65 per 100000 live births for White Tennesseans.18 On the basis of these statistics, TOMH used its grant to determine effective strategies in preventing heart disease and stroke among African American Tennesseans.
To meet this challenge, TOMH relied heavily on existing partnerships to quickly mobilize persons with expertise and resources sufficient to develop a meaningful response to these chronic conditions. TOMH had previously developed a mutual aid structure, which identified members' assets and was habituated to mutually sharing resources with African American communities in Tennessee. Therefore, TOMH had established capacity to enact a response.
In a self-reliant manner, TOMH rallied community activists and advocates (ie, TMHCDC), the faith community (ie, represented by more than 50 clergies from across Tennessee), the music industry (ie, the Gospel Music Association and associated artists), academics (ie, University of Memphis, Tennessee State University), and media and public relations specialists (ie, Details Unlimited). Each was a member of TOMH's mutual aid system. Through group problem solving, what resulted was a qualitative study about key health disparities conducted with African American clergy across Tennessee. The study's intent was to generate ideas that would support wellness and disease prevention among African American Tennesseans.
The TMHCDC through its local relationships with African American communities recruited African American clergy to participate. Clergy came from each of the six cities where TMHCDC had a presence. A cross-section of minority faith leaders was convened (fall/winter 2003) through focus groups to talk about their perceptions, opinions, and attitudes concerning the high rates of stroke in Tennessee minority communities. Clergy participants were also queried about faith communities' roles in redressing such disparities. A focus group guide was developed for the study by TOMH, TMHCDC, and its academic partners.19
A total of 57 faith leaders participated in the YHYH project study. Six focus groups were conducted with participants ranging in age from 30 to 84 years (average age 55 years). Participants were both male and female minority faith leaders drawn from six major cities/counties in Tennessee (ie, Memphis/Shelby County, Jackson/Madison County, Nashville/Davidson County, Chattanooga/Hamilton County, Knoxville/Knox County, and Johnson City/Washington County). Transcripts from the focus groups were analyzed for relevant themes and content. A list of major themes and categories was developed from discussions.19
Four major themes emerged from the content analysis, including (1) barriers to seeking preventive health services; (2) health behavior and utilization of the healthcare system; (3) barriers to building partnerships among minority faith leaders to prevent strokes; and (4) prevention through partnerships.19 On the basis of the YHYH project study, several recommendations were proposed, namely (1) instituting a faith-based movement to eliminate stroke among the people of color; (2) TOMH providing faith leaders with the technical assistance to build partnership infrastructure and develop action plans to reduce minority stroke incidence; (3) a neutral entity (eg, TOMH) assisting in coalition building, establishing an infrastructure for partnerships, and implementing a plan of action for stroke prevention; (4) identifying and working with faith leaders willing and committed to building health partnerships among the targeted populations; and (5) advocating disease prevention among African Americans, emphasizing adopting optimal lifestyles, having annual health examinations, overcoming mistrust of the healthcare system, and increasing the utilization of health services.19
Information gathered from the study was then incorporated into public service announcements reflecting pertinent disease prevention messages, employing themes and language from the Black Church. Messages reflected African American community assets. Popular Gospel music artists (eg, Dr Bobby Jones) served as spokespersons, reinforcing the faith-health connection. Media, including print and radio advertisements, were disseminated in minority-owned media outlets (ie, radio stations, newspapers, etc) during the spring/summer of 2004. Supporting African American businesses fostered economic self-reliance. Instead of using large, corporately owned media, the YHYH project used what it had, minority-owned media vendors. Doing this supported the physical and economic health of local African American communities.
The timing of the YHYH project proved fortuitous. Installed in 2003 as Tennessee's first African American Commissioner of Health, Dr Kenneth Robinson was familiar with the YHYH project and its recommendations. As a minister and physician, and former member of the MHAC, Dr Robinson understood the synergies between faith and health unlike any of his predecessors.
Capitalizing on the idea of engaging the faith community in health promotion and disease prevention, Dr Robinson hosted the Tennessee Faith-Public Health Institute, a collaborative venture with the Interfaith Health Program at Emory University in fall 2004. The institute convened teams of public health and faith leaders as partners in eliminating health disparities. TMHCDC and clergy from the YHYH project also participated on teams. As a requirement, faith/health teams identified issues to redress in local communities. The effort sought to build the capacity of the faith and health leaders to meet pressing health concerns. This was directly in concert with YHYH project recommendations. Consequently, many teams focused on heart disease and stroke.
Under Commissioner Robinson, the Office of Faith-based Health Initiatives (OFHI) was also established in 2005. This executive-level office was charged with developing faith-based health activities throughout Tennessee. It further provided technical assistance to faith-based organizations funded through the TDH. Through OFHI, four faith-based organizations (along with TMHCDC) received TDH contracts to implement the American Heart Association's Search Your Heart program, which emphasizes heart disease and stroke prevention activities. The Search Your Heart program was specifically designed for use in African American church settings.
The OFHI also developed an interactive DVD entitled, "Power in the Pews."20 The video includes an ecumenical representation of African American clergy in Tennessee, discussing their views about faith and health. The video provides an instructional how to on establishing a congregational health ministry.20 These activities, infrastructural changes in state health policy, and distribution of resources to African American faith communities were directly influenced by the output generated from the YHYH project.
At each turn, TOMH maximized resources to generate data and ideas, develop messages, and reinforce social networks to redress critical health concerns. As commissioner, Dr Robinson responded to the YHYH project's recommendations by making policy changes in TDH to support African American faith communities' involvement in health promotion. This response expanded the reach of TOMH and TDH to redress cardiovascular disease in African American communities. It did so by incorporating important assets from African American communities, namely the Black Church, clergy, and reciprocity into Tennessee's public health structure.
Discussion
TOMH serves as a model for mutual aid in action to redress African American health disparities in Tennessee. Using what it knew and building on what it had, TOMH mobilized resources and political will across Tennessee to change system dynamics that could promote African American health. It did so by creating a mutual aid system to change outputs for health. With limited funds and personnel, TOMH capitalized on mutual affinities, self-reliance, and fraternalism to meet health needs.
Currently, TOMH exists as a TDH office under the auspices of the Division of Minority Health and Health Disparities Elimination (DMH-HDE). DMH-HDE was created in 2007, through a merger of TOMH and the Office of Disparity Elimination (ODE) (2005-present). The merger, including OFHI, was outlined by these offices' leadership in 2004. The concept, along with organizational structure and proposed budget expansions, was presented to Commissioner Robinson and the Tennessee Black Caucus of State Legislators in late 2005. The idea behind what became DMH-HDE again reflected TOMH's mutual aid orientation. TOMH clearly recognized that combining the offices' assets (into a collective unit) could be beneficial. First, it minimized the risk that TDH funding networks established with African American faith and minority organizations would be easily dismantled under subsequent administrations. Years of collective wisdom made TOMH staff acutely aware of such a possibility.
The ODE and the OFHI were both created under Commissioner Robinson's leadership, but not supported by state statute. The likelihood that either of the two would remain under another administration was not guaranteed. A merger would help institutionalize these politically vulnerable offices. Bringing them together would furthermore underscore the connection between minority health, health disparities' elimination, and faith-health partnerships. The placement of ODE, OFHI, and TOMH under the DMH-HDE suggest that TOMH's concerns were legitimate. TOMH's concerns were serious enough in fact that DMH-HDE was instituted into TDH's structure. By collectively problem solving with other TDH offices, TOMH thwarted the threat to these offices' viability.
With the existence of DMH-HDE, Minority Health, health disparities elimination, and faith-health partnerships remain a part of Tennessee's public health system. TOMH is largely responsible for this. TOMH changed processes in public health that supported African American health. It brought skills, perspectives, and agents into connection with the TDH that otherwise would not have existed. TOMH also highlighted African American communities' assets to support health. TOMH achieved these outputs by using mutual aid as its primary practice strategy. TOMH staff committed themselves to using mutual aid. That strategy made TOMH effective in altering processes in Tennessee's public health system. Grounded in the belief that working with/for/on behalf of African American communities is the key to addressing challenges, TOMH brought identified agents and target groups together to make community, pool resources, and enact mutual efforts supporting African American health in Tennessee.
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