Americans protesting violent policing of Black communities are calling for law-enforcement budgets to be reallocated to community health services. Although such proposals are sometimes dismissed as naive or unrealistic, history provides an example of a transfer of power and resources from police to health services that benefited Black communities enormously. Pittsburgh’s Freedom House Enterprises (FHE) Ambulance Service not only supplanted the police in a role in which law-enforcement officers were not effective, but also reimagined the role of Black citizens in improving the community’s health and helped establish national standards for emergency medical care.
Freedom House Paramedics with Ambulance.
Photo credit: University of Pittsburgh
Freedom House was a community-based sociomedical program that aspired to “encourage Black enterprise” during the 1960s and 1970s by training Black community members to provide emergency medical services (EMS) (see photo).1 At the time, police officers and morticians without medical training supplied most prehospital “care,” generally providing transportation without medical treatment. Even Pennsylvania Governor David Lawrence’s 1966 death, which was partially attributable to inadequate EMS care, failed to galvanize improvements in emergency care.2 Moreover, EMS quality was often worse in Black communities. In this bleak environment, Freedom House enabled a group of disadvantaged Black laypeople to establish a model for paramedic training that ultimately set the U.S. standard.
The problems affecting Pittsburgh residents in the 1960s were similar to those we face today. The National Advisory Commission on Civil Disorders argued that the urban riots of the 1960s were a response to structural racism and socioeconomic inequity.3 Cities throughout the United States were rife with racist systems that precluded equal access to education, housing, employment, political opportunities, and social services.2 Black citizens were subject to unfair treatment by the carceral system and inadequate access to medical care.3 President Lyndon Johnson’s War on Poverty program sought to remedy these inequities by expanding civil rights and promoting public welfare, education, urban development, and public health programs.3 The Opportunities Industrialization Center and the War on Poverty initiative’s new Office of Economic Opportunity (OEO) increased employment opportunities by implementing job-training programs such as the Freedom House Ambulance Service.3
After World War II, municipal laws authorized police departments to provide emergency medical services.2 Many Black Americans relied on the police for EMS because they could not afford private hospital transport and because White operators of such services often avoided Black communities. Though the Emergency Medical Treatment and Labor Act of 1986 would eventually guarantee the right to emergency response and treatment regardless of one’s background or ability to pay, such provisions did not exist in the 1960s.3 Moreover, the minimum training standards for emergency responders fell short of evolving treatment standards.3
Then, as now, Black citizens faced discrimination and abuse by police and disproportionate rates of arrest and incarceration. Activists’ efforts to secure redress were rebuffed, as police leadership cited difficulties obtaining police-misconduct convictions.2 Consequently, many Black people felt a sense of indignity and fear when forced to rely on police officers for transportation to the hospital.2,3
So a biracial group of Pittsburgh leaders approached physician Peter Safar for guidance on equipping ambulance vehicles to transport Black patients to and from the hospital. In Baltimore during the 1950s, Safar and James Elam had not only proved the superiority of mouth-to-mouth ventilation in resuscitation, but demonstrated that laypeople could learn principles of artificial respiration. Safar and Elam went on to develop public-awareness videos and tools such as the “Resusci Anne” doll to teach and simulate artificial respiration. At the University of Pittsburgh Medical Center, Safar had achieved renown for developing cardiopulmonary resuscitation principles, creating the first multidisciplinary critical care unit in the United States, and designing mobile intensive care units.
Safar agreed to provide consultation on emergency vehicles in exchange for the chance to train Black community members to provide prehospital transport. The OEO helped recruit a Black workforce to undergo training, in a local approach to addressing racial and health inequities.
Fire and police departments vigorously opposed the ambulance service, which they saw as a threat to their autonomy.3 But even in this hostile environment, which persisted from the start of the program in 1967 until its demise in 1975, Freedom House proved largely successful. One study comparing its services with police services found that Freedom House paramedics provided improper treatment in only 11% of cases, as compared with 62% by the police.2
In 1973, Safar recruited physician Nancy Caroline to lead the Freedom House training program.3,4 Over her 2 years as medical director of what she called an “audacious, improbable experiment,”2 she transformed its leadership and was a steady presence in trainees’ lives. The program used classroom, hospital-based, and field training to teach basic anatomy, physiology, disease recognition and diagnosis, and common emergency conditions. Caroline connected with the paramedics personally while delivering rigorous training by regularly participating in ambulance rides and providing clinical oversight. She understood the importance of a sound foundation in critical care medicine, but as a Jewish female physician, she also recognized the importance of offering a sense of dignity and belonging to marginalized Black Americans.
Freedom House became the pilot course for EMS training for the U.S. Department of Transportation and the Federal Interagency Committee on Emergency Medical Services.3,4 Freedom House paramedics and the surrounding communities were proud of their accomplishments. Previously deemed “unemployable,” many trainees pursued advanced degrees, municipal leadership and state-level administrative roles, and advanced training in education, medicine, and allied health fields.1 Although some were able to find employment in municipal services, state-level leadership, and public health administration,1,5 others found themselves cast out and once again unemployed when the service was disbanded.1
White Freedom House employees had a different experience. As Caroline wrote, “for eight years, [Black Freedom House trainees] had stuck with the organization while they watched white trainees leave FHE to assume high administrative positions with City and County EMS agencies…. They [White trainees] had all done their apprenticeship with FHE, and now they were in control and Freedom House was odd man out.”3
Although Safar viewed work toward racial equity, economic opportunity, and health care access as complementary to his vision of national EMS standards, political opposition to his vision intensified in Pittsburgh.3 FHE initially received local, state, and federal funding, but Pittsburgh’s administration proposed to reduce funding for social welfare programs over time and cited Freedom House’s cost as a deterrent to further support. The city government’s subsequent creation of a more expensive and predominantly White citywide “superambulance” service, however, suggested that money was not the issue. Freedom House began preparing to close, and its board and city officials voted to dissolve it on September 22, 1975.3
The superambulance service employed predominantly White workers, jettisoning the social goals of Freedom House by excluding the Black men and women who had pioneered EMS standards. Seeing prehospital care as the “weakest link” in a continuum of critical care medicine,3,5 Safar focused primarily on nationalizing EMS standards — improving systems and protocols for emergency medical care through national organizations such as the National Research Council. In prioritizing standardization over community development and protection of oppressed groups, Safar’s choice set the tone for subsequent national structuring of police and emergency response systems, which relegated these functions to mostly White male professionals from outside the communities they serve.
The history of Freedom House is inspiring as an example of how physicians and a multiracial group of citizens can recognize a need for resources in Black communities and coordinate a progressive community-development program that raises standards of excellence for all. But it’s also a cautionary tale, demonstrating how well-intentioned leaders with their own agendas can undermine the goals of Black community empowerment while co-opting the products of Black innovation. History reveals various models of community partnerships, from the top-down political sponsorship of Safar to the bottom-up coalition work of Caroline. The Freedom House story suggests that though community health initiatives offer an alternative to systems like policing, the same racial and power dynamics can affect both. Whether recent calls to restructure community investment grow out of protests against police brutality or the need to rethink community health services, they raise critical questions about why we invest so heavily in racist systems that see communities of color as in need of help, but not equipped to also offer it, rather than supporting programs that protect and involve these citizens as agents.
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Race, Policing, and History — Remembering the Freedom House Ambulance Service - nejm.org
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