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Clinical Depression

The city wants out of its health clinics. Where does that leave its patients?

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Since the 1960s the Chicago Department of Public Health has been taking temperatures, administering vaccines, and providing prenatal care to Chicago residents who have nowhere else to turn for health care. That may be about to change, and the prospect has some residents and health-care advocates feeling more than a little queasy.

The CDPH now runs seven clinics around the city, but rumors of a plan to shut down its South Lawndale Maternal and Child Health Clinic started flying through the Little Village neighborhood last month. Located for ten years in a busy strip mall on 26th Street, the clinic--a no-frills place sandwiched between the Black Hole video arcade and a Discount Mall--had 16,700 patient visits last year. It offers prenatal and pediatric care and family-planning services to anyone who walks through the door, regardless of immigration status or ability to pay. Patients without insurance or medicaid--more than half of South Lawndale's clientele--are assessed fees on a sliding scale, with most paying $10 or less. Prescriptions for the uninsured cost $3.

"You could say we're closing South Lawndale, but I like to say we're moving the clinic," says John Wilhelm. Since Wilhelm became commissioner of CDPH last December, he's been preaching a new vision for the department. He believes the city needs to get out of the business of public medicine and back into the business of public health. That means gradually phasing out primary health-care services at the seven city clinics and redoubling traditional public-health efforts such as education, prevention, and home visits.

Wilhelm says the South Lawndale clinic will move from 26th Street to a former knitting factory at 2001 S. California, a mile away. He calls the new clinic a partnership between CDPH, the Cook County Bureau of Health Services, and Saint Anthony Hospital, which is just down the block. Saint Anthony's has taken out a long-term lease on the empty factory and will rehab it; the building will also house the hospital's administrative facilities. Wilhelm says the new clinic will offer everything the South Lawndale clinic has and more, including on-site high-risk-pregnancy services and specialty pediatrics.

He also says the move makes sense because the city and county already have partnerships with Saint Anthony's. For the past four years the hospital's midwives have staffed the South Lawndale clinic, and most of the clinic's patients deliver their babies at the hospital (women who want their tubes tied at the time of delivery are sent to Cook County Hospital). And for the past three years county doctors have run a high-risk-pregnancy clinic at Saint Anthony's. Saint Anthony's will be responsible for midwifery and pediatrics at the new site, and county doctors will move their high-risk-pregnancy clinic out of Saint Anthony's and into the new clinic. The city's role will be reduced to managing cases and running the federal WIC program.

Not everyone is convinced that the proposed changes are for the better. Little Village residents complain that the new location will be harder to get to; for many it will mean taking two buses--an unappealing prospect for pregnant women or those with small children, especially during winter. Susan Vega, cochair of the District 5 Health Council--a group of local health-care professionals and advocates that was established in the mid-90s to provide a link between the community and the city and county health departments--says, "It will not be a county facility, it will not be a city facility, it won't be a Saint Anthony facility--and we don't know what the effect on the community will be." Moreover, she says, no one has guaranteed that a visit to the clinic will still cost $10 or less or that the uninsured and undocumented will not be turned away.

Wilhelm responds, "From what I can see, Saint Anthony's does a lot of uncompensated care. Now, I'm sure there's always some that slip through, where someone will get billed. We'll work on it to make sure it doesn't happen. We're basically just picking up the clinic and moving it. The city and the county will still be there, and we do have a mission of assuring care."

Vega says, "Obviously a public entity that is run by appointed officials who are accountable to elected officials has a different accountability than a Catholic hospital, which is accountable basically to their board of directors and their sponsoring organizations, which are religious organizations or religious orders. Once it's under the net of a Catholic hospital, there are some things that even if they wanted to do they cannot do because they are Catholic."

On August 14 members of the community group ACORN organized a picket outside 12th Ward alderman Ray Frias's office. "Don't sell out!" and "Don't close the clinic!" read signs carried by two dozen protesters. They'd targeted Frias after finding out about a two-sentence letter he wrote in February to the city's Department of General Services regarding the health department's lease at the clinic's current location, which stated, "Given the incidents occurring over time at and around this facility and the general negative impact it has on the surrounding community, I am adamantly opposed to the renewal of this lease and will actively work against it."

Cristina Montoyo, a prenatal patient at South Lawndale who showed up for the protest, said, "The main thing is distrust, because that's what's happened in the past. They say things are going to be better, and afterward they forget about everything they promised. The government screws the poor."

Gloria Camarena, assistant to the alderman, says what Frias meant by his letter was, "The clinic is in deplorable conditions." She says patients have to step over bums and that drug addicts litter the area with syringes. She also says that pregnant women have to stand for hours because there's not enough seating, and that a shopping mall is no place for a clinic. Frias's staff called the police on the protesters, who were demanding a meeting with the alderman, and at one point Camarena shouted from behind the service window in his office, "The alderman does not meet with political organizations like ACORN!"

Wilhelm argues that this is a good time for the city to get out of the primary-care business. He says that while neighborhoods like Little Village might have been underserved in the past, local hospitals have opened clinics and now have a strong presence in many areas, thanks in part to federal funding programs that provide reimbursement for services to patients without medicaid or private insurance. He points to the Mount Sinai-affiliated Access Community Health Network, a federally qualified health center with 20 offices citywide that runs a brand-new clinic just three blocks east of the South Lawndale clinic. He says that in 1993 Cook County operated just three clinics within the Chicago city limits and it now runs 25. Last year there were 720,000 visits to those clinics; 72 percent of those patients had no insurance.

"Whereas my predecessor didn't have all these other clinics out there," says Wilhelm, "I really am very lucky that there is the county system, the Sinai system--that people are out there. I think that it's a good opportunity to let those folks do the primary care. We're a public-health department, so we should be in the public-health business. There's so much that needs to be done in public health, and it's not being done. We have to go to the people. As a health department, we have the data--we know which communities have tuberculosis, which communities are high in syphilis and other communicable diseases, which communities don't access prenatal care early enough."

He adds, "I think we should all do what we do best. Hospitals treat acute-care situations, primary care does primary care and links to the hospitals, and we should be doing more community-based activities. It was a good decision back in the 60s for the city to provide primary-care services for the indigent, because no one else was doing it. But now people are doing it."

Yet some people don't believe the health-care crisis for the uninsured has been solved even in neighborhoods where private clinics have set up shop. "If these places were providing the kinds of services that the community needed," says Vega, "why would there be droves of people going over to the South Lawndale clinic and the county facilities?" She says she's heard stories of private clinics in Little Village that won't give medicaid patients appointments on Saturdays. "I guess they think medicaid patients don't work," she says. And she says the wait for an appointment at the only county clinic in the neighborhood is more than two months.

One woman waiting to be seen at the South Lawndale clinic last week said she'd originally gone to the new Access clinic for an IUD. "The doctor didn't examine me at all," she says. "Then he told me it would be $300, but that if I went to his private practice he could do it for less." Access charged her $10 for the visit. That's when she decided to go to South Lawndale, where there'd be no charge for the procedure. She'd heard that the clinic would be closing. "It doesn't make sense," she said. "Why don't they put the services where the people are?"

Also at South Lawndale last week was a teenager who'd come for his high school physical. He too had first gone to a private practice in the neighborhood, but his mother decided the $25 fee was too high. "That's just for the physical," she said. "What if he needs vaccines or medicine?" At South Lawndale the physical was free.

A block and a half west, outside a storefront clinic run by the Sinai Medical Group, one woman said she brings her four daughters to the private clinic. "They give us an appointment for ten o'clock," she said, "and we're done by 10:30." Her daughters, who were born in the U.S., receive medicaid, but she still goes to the South Lawndale clinic because she isn't a legal U.S. resident and can't qualify for medicaid.

The city closed the first CDPH clinic at the end of July--the maternal-child health clinic it ran in the Grand Boulevard neighborhood, which served 1,100 patients per month. Wilhelm says it was in a Robert Taylor Homes building that was slated for demolition. He says CDPH won't open another clinic in the area because several county clinics already operate there. "But we are going to maintain a public-health presence in the community. We will work with the other providers and try to improve their immunization rates and entry into prenatal care. We will help the other providers by bringing patients to them."

According to one health-care worker in that neighborhood, the county clinics in the area weren't hurting for patients before the CDPH clinic closed. Now, he says, "We're being totally overrun. With one less provider in the neighborhood, it's just putting more stress back onto the ER system. And for those of us who are trying to help people access health care in a way that will really benefit them--by having primary-care providers--it's just more difficult. There's a crying need for more capacity, not less."

It's not likely that other clinics will be as easy to close as Grand Boulevard. Alderman Helen Shiller, who has a clinic in her ward, says she's let Wilhelm know what she thinks of his plan to get out of providing services. "I understand what he says about public health, and I think that the city should be doing public health," she says. "But it is only the public sector that will make sure that indigent people receive health care." She adds that the city clinics have been built and run with public funds. "We can't just now say we're going to turn it over to the private sector. Unless they're talking about a comprehensive agreement with county, where county agrees to continue [the clinics], I don't think we have any business having a discussion about getting out of the business of running the clinics."

According to Patricia Terrell, deputy chief of the Cook County Bureau of Health Services, the county is "developing a lot of mini plans" with the city to fit each neighborhood. She couldn't say how many of the county's clinics are at capacity.

Wilhelm says the next city clinic to close will probably be in Roseland or South Chicago. He says South Lawndale won't be moved for at least another year--Saint Anthony's hasn't started renovating the new facility. But changes are already being made at the clinic. Its administrator of eight years is being transferred downtown, and there are rumors that the pediatricians will be moved to other city clinics and replaced by doctors from Saint Anthony's.

Vega and others who've raised questions about the new plan for the South Lawndale clinic say they don't necessarily oppose CDPH's plan to adopt a more traditional public-health focus. But Vega believes the community should have been involved in the planning process and ought to have a concrete plan to react to. Wilhelm did promise at a community meeting in late July that District 5 Health Council members, some of whom have been involved in health care in the neighborhood for up to 15 years, will be included in future planning meetings. But Vega says several members think a public discussion of the wider issue--whether the city should get out of providing health care--is in order. "Some people have said, 'If there's going to be a fundamental change, it should not be just assumed that this is the only way to go,'" she says. "Let's have this discussion out in the open. The more people find out about this the more interesting I think the discussion will become."

Art accompanying story in printed newspaper (not available in this archive): photo/J.B. Spector.

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