By Elana Seifert
On the first Saturday in March, a few hours after the CommunityHealth clinic closes for the day, Dr. Serafino Garella changes into jeans and sneakers and begins framing walls for two new exam rooms. Working beside him are members of the staff and board of directors as well as community residents. "Like an old-fashioned barn raising," jokes Buck Taylor, the executive director, as one wall is lifted into place.
CommunityHealth, one of only two free clinics in the city, had moved two years before into this building, 1309 N. Ashland, which had served variously as a community meeting house, the headquarters of a Polish women's organization, and a church--the pews still serve as benches for waiting patients. Several examination rooms were built just before the move, and now two more, constructed largely with donated materials, are going in. Four years ago, when Garella opened CommunityHealth in another building, he and other volunteers went through the same process, building offices and exam rooms. Garella, who's never been paid for his work at the clinic, has always wanted as much of its limited money as possible to go to services.
Garella was inspired to found the clinic by a 1991 article he'd read in the Journal of the American Medical Association that, like many articles at the time, noted that 30 million Americans weren't covered by private health insurance but nevertheless didn't qualify for programs such as medicaid or medicare and that many of them couldn't afford to pay for their own care. But the solution it proposed was that volunteer doctors provide free medical care to those who couldn't afford it. The Italian-born Garella, who'd long been troubled by the American system of health-care delivery, was intrigued. "I grew up in a country that has socialized medicine, and I have always found it at least peculiar that this country--which is the richest country in the world and which can provide the best medical care to the fortunate people who have the money or insurance and knowledge--is unique in not guaranteeing some degree of medical care to everyone. I read about free clinics, and I thought, maybe if other people could do it we can too."
Garella, who's now 59, was born and raised in Biella, a textile center near the Swiss border. His father owned a small roofing and flooring business, and when Garella decided to drop out of school at 14 his father put him to work "to show me what real work was like. It's not pleasant work to bring boiling tar up a staircase. Especially since in those days we had to light the fire to melt the tar at four in the morning in order to start work at seven. By the end of the summer I knew that I would rather go to school."
Garella came to the United States in 1964 to do a one-year internship at Miriam Hospital in Providence, Rhode Island. "I always planned to go back, but one thing leads to another. You don't plan your life. You stay for one year, you feel like your training is not complete, so you stay on." After finishing his medical training at Rhode Island Hospital, he was offered a fellowship there in nephrology, which allowed him to do clinical research. That led to a series of positions at the hospital, and in 1973 he became director of the nephrology division.
In the 1970s medicare coverage was expanded to cover 80 percent of the cost of end-stage renal disease treatment, and doctors who opened for-profit treatment centers could become rich. But Garella saw that, as with most federal entitlement programs, plenty of people couldn't take advantage of these centers--primarily people who hadn't worked enough to qualify for medicare, people who couldn't afford 20 percent of the cost of the treatment. So he founded the Rhode Island Renal Institute, a nonprofit center for such patients.
In 1983 Garella came to Chicago to become associate chairman of the department of medicine and director of the internal-medicine residency program at Michael Reese Hospital, and in 1989 he joined the department of medicine at Saint Joseph Health Centers and Hospital as chairman and director of the residency program, a position he held until this summer. It was while he was there that he read the article that recommended that volunteer doctors provide free care for patients who had no insurance and weren't eligible for public programs.
Garella knew that in Chicago poor people without public or private insurance didn't have good options. Hospitals and charities had cut back their services. City and county clinics, which depended on federal and state funds, had been designed to provide health care to all city residents, regardless of ability to pay; they charged patients based on a sliding scale, but that scale often overestimated a patient's ability to pay. Moreover, a 1989 report by the city's Board of Health and the Department of Health had described waiting times for appointments that sometimes reached six months and shortages of qualified doctors, as well as problems with physical facilities, administration, and revenue collection.
When Garella approached funding agencies about start-up money for a free clinic, one of the first things they told him was that he would have to show there was a need for such a clinic in Chicago. He had just read the 1989 report. "I thought, how is this possible? Everybody knows that approximately 20 percent of the people are uninsured, and certainly in the city it's more than that. I thought, this is ridiculous--they want me, personally, to show them there is a need? But apparently they did."
Armed with a clipboard and his hospital photo identification and "trying to look like a nonthreatening person," Garella hit the streets, spending three afternoons knocking on doors to gather his own data. "I didn't do a complete sample obviously. And looking back, I really was not very smart about things. The blocks I explored were not even in the area that eventually most of our patients came from. They came from several blocks north of 3332 N. Ashland [the clinic's original address], from an area more densely Hispanic." But he did find out that "something like 40 percent of families in Lakeview had at least one member who was not medically insured and who could not afford to pay for medical care. In many cases only the husband or only the wife were covered through their work."
The funding agencies also wanted Garella to show that he had support in the community. He paid a visit to Francis Cimarrusti, then pastor at Saint Bonaventure on West Diversey. Cimarrusti remembers being impressed. "He had done a great deal of legwork already, talking to people and visiting Saint Basil's clinic [the city's other free clinic] and the Will-Grundy Medical Clinic [a free clinic in Joliet], so he was able to recognize what the challenges were already. He was very compassionate and very caring, and he had a plan. Parishes are tremendous resources--they know their communities well. Dr. Garella was aware of the kind of resource a parish could be--it was just part of his ability to understand and his willingness to learn what he didn't understand. Sometimes community organizers are afraid to come to parishes because they're afraid that, because of their tremendous resources and abilities, the parishes will take over. But Dr. Garella knew that in order to perpetuate his organization he had to learn, to reach out."
Cimarrusti became part of a group of about 15 community leaders and friends and colleagues of Garella who for a year met every month at Saint Bonaventure's to discuss the clinic. At one point they put an ad in a local paper calling for a town meeting, and more than 100 community members showed up. Cimarrusti says Garella wanted to hear everything. "Questions of need, ethnicity, race, background, economics, education, as well as practical aspects of finding space, how to get funding."
The funding agencies had still more demands--they also wanted Garella to show that he could gather together enough people who were willing to put time and energy into the clinic. "If I happened to be talking with someone, anyone--physician colleagues, nurses, social workers, or the sisters who ran Saint Joseph Hospital--I would talk about this thing," he says. Many liked the idea of a free clinic but doubted it could work in practice. Others had philosophical objections, including people who were interested and involved in social issues but feared that providing medical care on a volunteer basis could allow the government to abdicate its responsibility to the medically indigent. "Many people fear that, by doing this sort of thing--and by stuff like this I mean not just the clinic but organizing food or shelter for the people who can't afford it and a whole lot of other social ventures--it will exonerate the government, the country, and other people from doing something about the problem. That objection is particularly troublesome to me. Why? Because I agree with them! It is a social responsibility. The nation--the people of this country--should agree that basic medical care is a right."
Yet he didn't believe that argument should stop him. "The way I sort of am able to justify doing this is that, number one, I don't believe for an instant that free clinics are the solution to the lack of medical care in this country. This is going to take care of one percent of the people who need it. My second response is that each individual participating on a volunteer basis has the right to do what they think is correct. Finally, I believe that by participating in this social venture, we can go out and say, 'I have had personal experience--I know there are lots and lots of people who are deserving people, who are working just like you and me, and they deserve to have health care, just as they deserve to have a roof over their head.' We can be witnesses to this need, and maybe when the issue comes up again--after the nation has forgotten what happened in 1992 [when Clinton's attempt at health-care reform failed]--we will be able to help the nation understand that this is a real problem. I've always felt something should be done about the fact that this country is unique in not guaranteeing some degree of medical care to everyone. Given that I'm not good at politics or even interested in it, this was the only thing I personally could do to help."
Garella also ran into people who didn't believe it was right that those who volunteered in a free clinic were protected from civil liability by the state's "Good Samaritan" act so long as they were treating the "medically indigent." These people believed it was unfair to ask the poor to give up a right to sue in exchange for the privilege of getting medical care. "I have two answers to that," Garella says. "First is that if physicians and nurses felt there was a high likelihood of being sued while doing volunteer work they just wouldn't do it. Making that trade-off may be right or it may be wrong. At this point I don't really care. The law's purpose is not to deprive the poor of their capacity to sue. The fact is, we are working here under severe constraints, and the law accommodates that.
"Let me give you a simple example. Let's say a patient comes here, and I feel that the best medicine I could give them, the medicine I could prescribe to one of my paying patients, would cost $165 a month. Now there is another medicine that has been on the market for a number of years, that somebody happened to donate to the clinic. It's not as good as the first, it has more side effects. You put the question to the patient. You say, 'What you really need is this first medicine. Do you have the $165?' If the patient says yes, they shouldn't be there in the first place. But if they say no, then you say, look, we have a second choice, which is not as good, but I can give it to you for free. And they take it. Now let's say they get the side effect. How could you possibly accuse the caregiver of doing something wrong? If you want to shut the clinic down and keep people from getting any care, that's a good way to do it.
"The same applies for expensive diagnostic tests. If the patient doesn't have the money to obtain the test and something bad happens while you take another course, well, you just couldn't have done it anyway. That's the purpose of the law. We have constraints of time, of medications, of testing, of care. People can get no care or maybe not state-of-the-art care but what I believe is pretty good care. The people who object should give us the means to provide state-of-the-art care--then we'll be open to malpractice liability." He could also point out that the "Good Samaritan" act offers no protection against a lawsuit when an injury results from a professional's "willful and wanton" negligence, and that doctors receive no immunity for any criminal actions they commit in the course of providing care.
Nevertheless, Garella found many people who were willing to help, and he used each positive response as leverage with the next person he spoke with. "To tell the truth, most of the people who said in the beginning that they would help out didn't, but I was able to go to granting agencies and say, look at all these people willing to help."
Garella often tried to recruit relatively new physicians. "Typically what happens is, unless a doctor goes to work for a large organization or an HMO, they start out with very few patients. So they have free time. There were exceptions--people who worked in HMOs, people who had taken administrative roles but who wanted to keep a hand in medicine and keep their skills up, and some residents who wanted to work under supervision. But people these days who are in their 40s and 50s who have an established private practice are working very hard. They really do not have any free time. Most of my colleagues work at least 60 hours a week, maybe more. Many have evening hours. Some have Saturday morning hours at least a couple of times a month. How could I ask someone like that to come here another evening a week? They're already not seeing their families enough as it is." Garella has four children, but they're all grown.
Two grants totaling $25,000 eventually came through from the Prince Charitable Trusts and the Chicago Community Trust. The money went to pay rent and the salary of a part-time coordinator, and on May 17, 1993, CommunityHealth opened its doors at 3332 N. Ashland. The Lakeview location was chosen largely because it was close to Saint Joseph's, where Garella and many of the physician volunteers worked, and because it was where Garella had done his survey. But there was an additional factor. "Because we were going to be counting on volunteers," says Garella, "we had to be located in an area perceived as not dangerous to go in the evening or at night." Englewood's Saint Basil's Free People's Clinic had found that some doctors were reluctant to drive to the clinic to volunteer.
At first the clinic's supplies were short. "When I first started coming here we only had one or two otoscopes and ophthalmoscopes," says Dr. Enrico Villanueva, a Saint Joseph's resident. "Now we have everything--equipment, medications, and specialists coming in all the time." Abbott Laboratories donated pregnancy and strep tests, Loyola University School of Dentistry donated three dental chairs and three X-ray machines, and Welch-Allyn Institute donated all the clinic's medical instruments. Their names and many others are printed on signs--labor and materials donated--that hang on the clinic walls. The pharmacy is now stocked with more than 150 different medications, all donated. A major national lab donates about $3,500 in laboratory services each month. Individuals as well as institutions such as the Scholl College of Podiatric Medicine and Cook County Hospital provide some referral services free of charge.
The first night the clinic was open it served three patients. Last year there were 7,000, and 8,000 are expected this year. The vast majority are Hispanic, and most are women and their children. Many are recent immigrants. Most work; some are self-employed, others are seasonal or part-time workers. They have jobs in restaurants and in construction, they drive cabs, they clean other people's houses and care for other people's children. If their family's income is less than twice the federal poverty guideline and they're not covered by public or private insurance, their care at CommunityHealth is free.
The clinic is open four nights a week, Friday afternoons, and Saturday mornings. There are only two full-time and four part-time paid staff, with an expense budget of $195,000 in 1996. Garella, who isn't one of the paid staff, figures he puts in up to 20 hours a week, between meetings and fund-raising and patient care--in addition to his current full-time job, as a professor of clinical medicine at Northwestern University. But he laughs at any suggestion that CommunityHealth represents some sort of sacrifice for him. "Look, if I didn't do this I might be playing golf. For people who enjoy this, it comes to be not like work." Though it might seem that he should be continually pressed for time, Garella's colleagues describe him as extraordinarily patient with volunteers and patients. "He's the kind of guy who will take an hour explaining something complex to someone, have another person come up to him and ask the same question, and will explain the same thing for the benefit of that person, taking up another hour of his time," says Clayton Williams, the clinic's volunteer coordinator.
Virtually all the work is done by more than 200 volunteers; an additional 100 or so medical students and residents also work for credit. The volunteers come from a wide spectrum of backgrounds and perspectives. Jorge Rios, who six years ago came to this country from Mexico, volunteers as many as 30 hours a week as a phlebotomist, HIV counselor, and translator in addition to putting in 30 hours working at an Old Town restaurant. He first came to the clinic as a patient. "They didn't ask for anything except do you want to volunteer." Greg Brisson--a physician, concert pianist, and triathlete who has a private practice and teaches at Northwestern University and the Rehabilitation Institute of Chicago--volunteers seven hours a month at the clinic. Jane Halleen, who works at the Buehler Center on Aging at Northwestern University and starts medical school at the University of Chicago in the fall, has been volunteering as a translator for more than a year and a half. Assuming a figure of $100 per patient visit--including tests and medication--the clinic returns more than $3 of health care for each dollar in its budget.
Joy Glazer is a nurse who's been serving as CommunityHealth's clinic manager since the beginning. She and another doctor had run a free storefront clinic in the 60s, so when she met Garella during the town meeting she knew she wanted to be involved in CommunityHealth. "There were people at the meeting who said this could not be done--you'll never get enough volunteers, you're not federally funded, it'll never happen. But we knew it could. Dr. Garella is a visionary, a dreamer."
But Garella says, "This is not about me. Look, when we started this thing we had three goals in mind. The primary goal was to provide primary and preventive care to people who cannot otherwise afford it. But I also wanted to see if it would be possible to get health professionals--especially young health professionals, before they go out into the world, so to speak--to come here so they would be exposed to the needs of the inner city and to learn about it and perhaps become interested in changing the system. The third goal, I suppose, was to indicate to the community at large that doctors and nurses and other health professionals still do have a streak of volunteerism." o
Art accompanying story in printed newspaper (not available in this archive): uncredited photo by Jim Alexander Newberry; Serafino Garella photo by Jim Alexander Newberry.