Health Care Among the Poor: The Vanishing Promise
by Art Jones, CEO

At one time, universal health insurance in the United States seemed not only possible, but probable. The public debate focused on which would work better-a single-payer system or an expansion of our current system. Then the argument has shifted to shrinking the welfare system. Gaping new holes have appeared in an already tattered health care safety net.

An increasingly competitive environment makes it harder for health care providers to continue to serve the poor and medically underserved, as cost shifting becomes more difficult. Conservative rhetoric about the dependency-creating effect of the welfare state suggests that service to the poor is only contributing to the problem. If government is going to cut its support and medical service to the poor, why should we rush to fill the gap?

The institutions which serve the poor are under the greatest financial pressure to close. Since few health care providers live among the poor, the geographic isolation of providers from those in need is feeding a domestic isolationism: Why not focus our limited resources on our own immediate communities? Won't providing health services to the poor make us less competitive and threaten our long-term viability?
The integrity of the health care profession is on the line. Will we simply follow the market forces? Or will we maintain the commitment to serve those in need that has always characterized our profession? Will we compromise mission for expediency?
Admittedly, most attempts to improve the health status of impoverished inner-city communities have met with frustration and failure. But that doesn't mean the task is impossible. In fact, my experience has shown me that it can be done.

An Idealistic Vision

I entered medical school with the goal of eventually using my skills to improve the health of a medically-underserved population. Because of the mission emphasis of my church upbringing, I initially envisioned working overseas in a third-world mission setting. As a third-year medical student at the University of Illinois, I began to attend a small Protestant church in North Lawndale, an African-American community on Chicago's West Side, which has been one of the poorest and most medically underserved areas in our country.

That church of 25 people decided it needed to do more than preach the Gospel on Sundays; it needed to demonstrate its faith throughout the week by addressing the needs of the community. One Sunday morning the pastor put up a blackboard and asked the congregation, What are the most compelling needs of this community? One of the first needs mentioned was affordable health care services, especially for the uninsured poor.

As I got to know people from the neighborhood around the church and began seeing through my clinical clerkships at CookCounty Hospital how the health care system was failing the poor, I changed my focus from working among the poor overseas to working with the poor in my own back yard. During the rest of my time as a medical student, as well during my internal medicine residency and cardiology fellowship at the University of Chicago, I worked not only to learn medicine, but also to learn about the lives of the patients I would eventually serve.

My wife and I bought a home in North Lawndale and moved in, doubling the community's white population from two to four. Although we met with some initial suspicion, my African-American neighbors were much more accommodating to us than the northwest suburban community I grew up in would have been if someone from Lawndale had tried to move in there.

It wasn't uncommon at that time to pick up a newspaper and read about some physician who was raking in huge sums of money running a Medicaid mill. Since I was content to earn a modest salary, I assumed I could easily set up a practice that would subsidize care for the uninsured with my Medicaid earnings. Reality would not turn out to be nearly so simple.

The Challenge of Reality

In 1983, I attended a conference on health care for the inner city of Chicago. While the conference did a good job of defining the problem, the mood was pessimistic when it came to envisioning solutions. The room was filled with talented and committed health care professionals and administrators who genuinely cared about the poor, but who seemed discouraged that their years of efforts had not solved the problem. It was a sobering time. For the first time, I began to second guess my lofty plans.

At the end of the conference, I introduced myself to Rolf Gunnar, the chair of one of the agencies sponsoring the conference. I wondered if he would have the time or interest to talk with me. Would he judge my dream to be as foolish as some other medical professionals already had? Rolf, however, seemed relieved to find even a glimmer of hope and agreed without hesitation to meet with me. I left with renewed hope.

I later met with Rolf and outlined our plans. He believed in our project's potential and helped us get the foundation support we needed to start the Lawndale Christian Health Center (LCHC). That community health center now provides over 60,000 medical and dental visits per year to an impoverished African-American and Hispanic population. We offer extensive support services to complement our medical services, and we partner with the church and others to improve the community we serve. We have seen many of our young people return to the community with their college degrees to provide leadership in the health center and partnering agencies. Infant mortality in North Lawndale has dropped from the mid-20s when we began, to 12.8 deaths per 1,000 infants. Today 80 percent of our operating revenue comes from patient revenues.

But this didn't all happen just from opening our doors and watching the clinic grow. Along the way I have discovered four principles that have proven essential to our ability to provide effective health care in our neighborhood.

Principle 1: Community Ownership

In North Lawndale, the community itself felt the need for affordable health care services and was committed to work to address the need. Control of the project came from within the community; it was not simply imposed by well-meaning outsiders.
For $35,000, we bought a condemned building that had housed a Cadillac dealership until the riots in the late 1960s. Although some urged us to tear the whole thing down, a volunteer architect felt the building still had potential and drew up plans.
The first step was to repair the roof, which had gaping holes up to 30 feet across. The estimate to repair the roof was $90,000. We had yet to attract our first grant and had nowhere near that amount, so we used the resources we had-the volunteer energy of the community. We bought a saw and ripped off the roofing all the way down to the rotted wood deck. After repairing the deck, we did the rest of the job for $20,000. Our community volunteers had saved us the first $70,000 of rehab costs. What other cardiology fellow could enjoy the variety of learning to do a cardiac catheterization by day and roofing by night?

During spring break, Mary Gugenheim of the Chicago Community Trust visited us unexpectedly in response to a grant proposal I had submitted. She found over 20 high-school-aged volunteers working up on the roof. Though we had not yet seen a single patient and had only the credibility we could borrow from Rolf and others, the degree of community commitment to the project was enough to convince her to fund us. That same volunteer spirit convinced suburban contractors to help us, too.
Over the next six months, we resurrected those ruins into a 15,000 square foot facility that housed the health center, the church, and a gymnasium. These hundreds of volunteers built much more than a facility; they also built a deep sense of ownership. Even today, this totally white building remains free of the graffiti that defaces much of the community.

Principle 2: Relocation

From the beginning, we determined that the staff for the project would either be current residents of the community or would relocate into the community. This would enable our staff to identify with our patient population and understand their daily lives, including how their lifestyles impacted their health and behavior. As neighborhood problems became staff problems as well, we became motivated to address some of the non-medical problems that affected health.

When we had trouble finding adequate housing, a development corporation was formed to rehab deteriorating housing and sell it back to people from the community at affordable prices. A substandard public school system triggered the creation of after-school tutoring programs. The lure of gangs was countered by youth programs that would give kids a sense of belonging. By financial necessity, in the early days, the health center staff agreed to work for well below market wages. Because of this, and because we required staff to relocate, we attracted only the most committed of staff.

Principle 3: A Holistic Approach to Health

When we opened in September 1984, we got in on the end of school physicals. We were surprised to find that most of those five-year-olds were way behind on their immunizations and had missed out on many of their well-child visits. One year later, when five-year-olds once again came in for school physicals, a similarly high percentage were under-vaccinated. Clearly, our traditional approach to health care was not making the difference we had hoped for. It was time to try something different. We adopted our first nontraditional strategy when we hired Vanessa Little from the neighborhood as our first case manager. Although she never finished high school, she was bright and energetic, a good communicator, and had three small children of her own. Her job was to follow up on families who brought their pre-school children in for illnesses but not for well-child visits. Vanessa soon proved to be the best investment the health center had ever made. She was far better at convincing mothers to bring their children in for their shots than any of our providers.

We now complement our traditional medical services with various creative approaches to health education, prevention, and outreach. One example is our outreach program for pregnant patients. Frustrated that so many patients waited until their second or even third trimester of pregnancy to begin prenatal care, we decided to go to them instead of waiting for them to come to us. LCHC is located across the street from the Western Public Aid office. With the help of United Way funding, we now place outreach workers in the waiting area of the public aid office. They mingle with clients who are waiting for appointments with their case worker. Women who think that they may be pregnant are offered pregnancy testing. When the test results are positive, we ask if they would like to see a physician that day for their first prenatal visit. Most agree.

We then send a physician over from the health center to give the first prenatal exam, using the examining room Public Aid let us build in their offices. We then schedule a follow-up appointment with the physician of the patient's choice and follow the patient until that first visit. Patients choosing LCHC are case managed throughout the remainder of their pregnancy. About 50 women each month receive their first prenatal visit this way. On average, women contacted through this outreach effort begin prenatal care a full four weeks earlier than our other pregnant patients.

Principle 4: Leadership Development

Impoverished communities like North Lawndale have trouble holding onto indigenous leaders. In fact, one standard measure of success in poor neighborhoods is the ability to leave the neighborhood behind for more affluent surroundings. Unless this leadership drain is stopped, there is little hope for overcoming the problems so prevalent in these communities.

By developing tutoring, youth programs, and job opportunities for youth, we have been able to encourage many of our youth to pursue a college education. We maintain communication with these college students and offer them summer employment with the same youth programs they grew up in. They see the opportunity they have to influence younger kids in the neighborhood. They also see staff, including professionals, who have chosen to live in North Lawndale, and the stigma of staying begins to disappear. After 20 years of such efforts, much of the leadership of the church, health center, and related ministries is in the hands of indigenous leaders who have been empowered to make a difference.

Distressing Trends

Today in North Lawndale, health care is accessible to people of all incomes and is complemented by the necessary health support services. But that does not mean I see the prospects for health care for the poor getting brighter. I have seen distressing trends in our political leadership and in the national mood. In the early 1990's there seemed to be momentum to establish universal health care coverage in this country, as is available in almost every other industrialized country. People seemed to understand that we were investing more than enough on health care in this country, but that we were not spending it very wisely. If only we could establish a system that eliminated the waste, there would be plenty of health care resources for everyone. The days of that kind of thinking seem a distant past.

The United States boasts of the best health care in the world for those who can afford it. Medical research has prolonged and improved the lives of many and the potential for continued advances is bright. The outlook for the poor, however, especially those in concentrated pockets of inner-city poverty, is bleak.

A Strategy that Will Work

We can't solve the problems of the inner city by throwing money at them from a distance. They call for direct personal involvement. We must reintegrate our inner city-communities with people of diverse economic, racial, and social backgrounds. We need some of the best and brightest of our profession to choose to live and work in the areas of greatest need. They need to experience firsthand the problems of these communities, then work side-by-side with other residents to design and implement solutions.

Both government and the health systems serving the greater community must join in committing resources to fund such an approach. We must not use unsuccessful past investments in the inner city as an excuse to cut off resources. Rather, we must learn from our mistakes how to invest more wisely.

Medical professionals, rather than lobbying to protect our own interests, must actively lobby to protect the poor. We must reaffirm our commitment as health care professionals to serving the health care needs of all in our society, and champion public policy that seeks this goal, even if it means less income for us.

We have a choice. We can use our power and responsibility primarily to benefit ourselves, or we can use it to serve others, especially those least able to protect their own interests. Which we choose will be judged by society and, more importantly, by God.

Medical breakthroughs have come through perseverance in times of failure. They have resulted from intimate involvement with the problem, creative thinking, dedicated resources, and commitment. In the movie "Apollo 13," the flight director met catastrophe head-on with the words, "Failure is not an option." When Americans are lost in space, the country's best minds go to work with intense resolve. They don't stop until our people are saved. Saving Americans who are lost in the inner city due to broken homes, inadequate education, uncontrolled violence, and a broken welfare system will demand nothing less.
Art Jones, M.D. is an internist and is President of Lawndale Christian Health Center on the West Side of Chicago. He has lived with his family in North Lawndale since 1979.

This article was originally written in 1995 and edited for publication on the Internet in 2001.