Dr. Eva Salper –Community Health Pioneer and Author

Science rewards its luminaries with the Nobel, Lasker, or Wolf prizes, among others. Recognition for public health stars comes with presidential appointments or awards, such as those given to Dr. Everett Koop or Dr. Francis Kelsey. Alas, pioneers in community health often go unrecognized. Jane Addams, the founder of Hull House and a pioneer of the settlement movement, did win a Nobel Prize – in Peace (for her political stances); Lillian Wald, who initiated the Visiting Public Health Nursing service, was inducted into the National Women’s Hall of Fame, but her name has largely faded from public discourse. In an era where Medicaid is being dismantled,  recognition of  Dr. Eva Salber, whose work pioneered many of its initiatives and whose research contributed to our understanding of providing optimal health care for the poor and disenfranchised, but which has gone largely overlooked .s finally due.

“A decent provision for the poor is the true test of civilization,” Samuel Johnson, quoted by Dr. Eva Salber

Born in 1916 and raised in Cape Town in apartheid South Africa, Eva Salper earned her medical degrees (an M.B.Ch.B., the equivalent of an M.D.) in 1938, a diploma in public health in 1945, and a doctorate in medicine (M.D.) in 1955. Her exposure to the care and treatment of the Black population affected her career trajectory, generating an interest in the health of the poor, the Black, and the disenfranchised, which was to endure throughout her life. In 1946, she joined the newly established South African Institute of Family and Community Health, which was established for training and research in support of a national healthcare program. “At that time, her focus was on the social aspects of child rearing as seen from a multi-racial perspective.”

By 1956, with wartime commitments ended, Eva and her husband, also a public health physician, emigrated to the US. Finding employment without a US degree was difficult. But eventually, an opportunity arose that suited her training and experience: supervising medical Harvard medical students in well baby care,  suitable, but far from her first love: research. 

Coupling her compassionate bedside manner with an interest in epidemiology, she was among the first to investigate breastfeeding (or the lack thereof) in the Black population in Boston, cigarette smoking in teens, and drug addiction, including introducing the use of epidemiology in studying disease trends. 

By the early 1960s Eva had earned the respect of Dr. Brian MacMahon, the chair of epidemiology of Harvard Medical School, who asked her to take on the directorship of two new health initiatives: one involving inner city health in low-income housing projects and a Maternal and Child health program for the poverty stricken, the impetus and funding was driven by the Kennedy family who was interested in the incidence of mental retardation, which seemed to proliferate in premature babies.

“The purpose of one of the two Children’s Bureau Grants – the Maternity and Infant Care grant- was to reduce prematurity,” believed to be one of the causes of mental retardation, and thereby prevent it, along with reducing infant mortality. 

The approach contemplated providing skilled services to pregnant women in the impoverished populations, under the aegis of two prestigious Boston hospitals. Eva Salper was tasked with uniting the two units into one overarching healthcare facility, a position she undertook in 1967 as the Director of Harvard’s Boston Hospital for Women and its Children’s Hospital. She saw her role as planner/educator evaluator, since in Eva’s world, health goes hand-in-hand with health education. She also aimed to improve people’s emotional as well as physical health. In addition to hands-on services, her epidemiological research unit provided data on the health behavior of the population

Her previous training in South Africa in community involvement and health education stood her in good stead, although the political discord differed: in the US, the conflict pitted black inner-city residents against the poor Irish outside.  Complicating the poverty, drugs, and block to upward mobility was the rancor and bitterness of the two populations.  Religion and racial prejudice proved an especially toxic combination

Nevertheless, even as she was subjected to danger, threats, abuse, and more, Dr. Salber succeeded in developing “Bracken Field” into one of the largest housing projects in Boston into a model for health provision, treatment, and education, serving the low-income population of pregnant women and children. 

The problems presented by the Black population are reminiscent of today. In most families, fathers were either absent, sick, or disabled. 60% of project families subsisted on welfare. “It was a world of troubled mothers with children to support.”

Her work focused on utilizing epidemiological studies to assess the relationship between social factors and health, as well as related community health issues. Among her notable contributions were studies on infant growth in different racial groups, socioeconomic patterns in breastfeeding, smoking behavior among schoolchildren, lactation and breast cancer, and social factors influencing the utilization of health services.

One notable accomplishment was involving community members, a concept referred to today in public health theory as incorporating stakeholders. Salber’s community project included initiating a unique and novel program that involved recruiting community activists and forming a “Health Advisory Committee,” which gave them both responsibility and a voice in the development of healthcare, education, and practice. The advisory group served to encourage community leaders to take responsibility for their health and welfare as well as serving as examples to their constituents,  recounted in her numerous articles and the book, Caring and Curing: Community Participation in Health Services, In the space of barely two years, Salper’s imprint changed the delivery of health care and increased the self-esteem of residents, enabling some to later secure high-level positions in local and state government.

The More Things Change

One of her team members told her that before moving into Bracken Field, she thought of poverty as a lack of food and clothing. Now she learned it meant living in a poor neighborhood as helpless victims of crime and violence. “No one really cared about the poor in America.” 

Within a year of full start-up, more than half of eligible families had registered as patients, even as those from outside the project were fearful of being attacked. Her experience taught her that “diseases resulting from societal inequities can’t be cured by medical care alone- no matter its excellence.”

By 1968, political discord made it impossible to continue, and Eva resigned- although she had carefully arranged the framework for its continuation. During her tenure, tens of thousands of children were treated, hundreds of lives saved, and thousands learned the basics of health education.  She spent her next year as a Senior Associate at the Harvard Center for Community Health and Medical Care. In this assignment, she and her associates investigated 6000 children and 2000 women of childbearing age –documenting the disparities in health care between the Black and white population, and offering them services at the Harvard Medical Center, while conducting epidemiological surveys regarding residents’ reactions toward health institutions and persons from whom they got their health care. 

“Even today, [1989] Boston, with its unparalleled specialist resources and its extensive network of neighborhood health services, has higher mortality rates for black and low-income infants and young children.”

The Next Adventure

The Boston experience did not die with Eva’s resignation. Following her husband (as women in did in those days), Eva Salpber relocated to North Carolina where she was eventually, was appointed Professor, Department of Community and Family Medicine, again developing health services for a low-income population, this time by serving as consultant to the Lincoln Hospital in Durham, then the process of converting from a segregated institution to a community health center. Her work provided the data for research on rural health utilization and a study of the lives of elderly people living alone in that area. 

In another project, reminiscent of her Boston Health Advisory Group, Dr. Salber demonstrated her faith in the latent strengths of ordinary people by devising ways of identifying the natural helpers in health matters in the community and enhancing their effectiveness through special training programs, described in her training manual, “Community Health Education: The Lay Advisor Approach.”

In 1971, Dr. Silbar returned to academia, joining the Department of Community and Family Medicine at Duke University, where she served as a consultant to the Health Planning Council. The Council assembled a group of 100 Durham residents, divided into three groups, to study community health. Their report provided three recommendations:

Expanding primary care centers,
Encouraging group practice
Using auxiliary medical and dental workers, and
Expanding health education of the public.

Most of these were adopted with great success.

One personal suggestion included expanding access to low-income housing- an idea generating incredulity that this concept might have anything to do with health.

In addition to being a voice and a force for providing care and education to low-income, underprivileged populations, compiling data in the form of epidemiological studies, and delivering healthcare, Eva Salper provided a unique voice for those in these disadvantaged groups, including the aged, the poor, and the “lonely.” Her book, “Don’t Send Me Flowers When I’m Dead: Voices of Rural Elderly,” gives these people a voice and is surely worth reading.  Eva Salber died in Chapel Hill, NC, in 1991, not far from the poor she took care of.

Entries about Dr. Salper’s work are in short supply compared to others. Her autobiography, “The Mind is Not the Heart: Recollections of a Woman Physician,” is a necessary read about a forgotten heroine.