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Just Pure Medicine

May 6, 2007
By HILARY WALDMAN, Courant Staff Writer

When the pipes freeze, there is no running water.

The lighting is so dim that there are times the gynecologist has to use a flashlight to guide her as she performs a Pap test.

But the doctors and nurses never turn anybody away; and nobody ever is asked for an insurance card when they arrive - or for payment when they leave.

Three afternoons a week, a band of volunteers park an old Airstream camper near one of Hartford's Catholic churches, open its stubborn door, and put out a yellow plastic step stool because the hydraulic stairs no longer work.

The Malta House of Care is open for business.

While a national debate over covering the uninsured rages in Washington, and dueling plans to extend health coverage to everyone in Connecticut hover in limbo at the state Capitol, this tiny group of volunteers in Hartford is doing it the old-fashioned way.

Patients wait for the camper - the size of a city bus - on folding chairs in drafty church basements. Medical records are kept in plastic Rubbermaid bins. The volunteers take on multiple tasks: Felix Ortiz, for one, does triple duty as the van's driver, security guard and translator.

"This is what I call pure medicine," says Dr. William Harris, a 55-year-old family physician who closed his Windsor practice because he was tired of fighting with insurance companies and constantly looking over his shoulder for the next malpractice lawsuit. Now, Harris, who is semi-retired, volunteers at the mobile clinic one afternoon a week.

Today, he is caring for Juana, a 56-year-old woman with hollow eyes who grips the walls of the clinic to stay upright because a stroke nearly destroyed her balance.

Two weeks earlier, Juana explains, she'd been sitting in her church when the sanctuary started to spin. The nausea made her vomit right there, in the pew. One side of her face went slack. She tried to stand up, but her body would not budge.

Hours later, she woke up at Hartford Hospital - the first time she had seen a doctor since she came to the U.S. from the Dominican Republic six years earlier. All that time, high blood pressure and diabetes were quietly conspiring to set off a major stroke.

After four days in the hospital, Juana was sent home with a week's worth of medication and a discharge order that was both simple and impossible:

"Make arrangements for insurance and get a family doctor, fast."

The hospital might as well have told the woman to go out and buy a mansion with an in-ground pool.

As it is for almost 400,000 Connecticut residents, routine medical care is largely out of reach for Juana. Some of the uninsured, like her, are undocumented immigrants. Most are low-paid citizens who are not offered or can't afford employer-based health insurance.

Two weeks after her stroke, Juana is still not feeling right. She has no energy, her head and neck are throbbing and she cannot walk without the aid of a walker - or the walls. A friend from church sent Juana to the mobile clinic. The operators distribute fliers at area churches, and many of Malta's patients arrive clutching one of the photocopied sheets promising free care.

After a brief examination, Harris sends Juana for blood work and prescribes medication to begin controlling her blood sugar.

None of it will cost her a dime.

Time, Not Money

A few miles away, Jean-Pierre van Rooy settles into his favorite table at The Hartford Club and orders a glass of pinot grigio.

Now 72, van Rooy retired 10 years ago as chairman of Otis, the world's largest elevator maker. He wears the trappings of wealth comfortably, from the silk handkerchief in his blazer pocket to the shiny Audi Quattro he parks in the club's underground garage.

With his wife, Marie Claire, van Rooy's philanthropic endeavors are vast. A $10,000 musical prize bears the couple's name, he serves on the boards of St. Francis and Bristol hospitals, and has traveled to Haiti on medical missions. Van Rooy and Otis also have been major sponsors of the Special Olympics.

But a staph infection that almost killed van Rooy seven years ago prompted him to re-examine his life and his legacy.

"Once you have bullets pass by your head, there are some things you think about more," the Belgian native says, his English still heavily accented.

When he recovered, van Rooy joined the Order of Malta, a Catholic missionary group that traces its roots to Jerusalem 900 years ago, when knights served food to the sick on silver platters, for sanitary, not aesthetic reasons. Buffeted by the conflicts of history, the order fled to Cypress, Rhodes and finally Malta. Today it is a benevolent organization whose mission is still to heal the sick.

It would have been easy for van Rooy to fulfill his obligation to his new order by underwriting a hospital wing. But he gets no satisfaction from writing checks. A child of socialized Europe, he had long been struck by the figures printed so frequently in U.S. newspapers - 40 million Americans living without health insurance.

He is skeptical that politicians will fix things. Even in Europe, where health care is paid for through taxes, access to care is a problem, especially for immigrants. Regardless of government action, van Rooy believes there will always be people at society's bottom for whom the doors to decent health care remain shut.

For them, care must be free.

Van Rooy was determined to make it so.

In Hartford, he was certain, somebody would donate a building. Doctors and nurses who volunteer so readily in Africa and South America surely would do the same at home. They would treat anybody who showed up, no questions asked.

As a former CEO, van Rooy grew accustomed to coming up with ideas and having the clout to see them through. Suddenly, in this new pursuit, he was frustrated in his search for a building and aggravated by doctors who said they'd love to help out, but couldn't risk the malpractice exposure.

In the middle of the night, when he does his best thinking, van Rooy considered his options. He had driven past a bus shelter once and saw four men shivering inside. Perhaps one had a fever. Were they headed for the emergency room? What if he could bring health care to them instead? He had seen mobile clinics that provided mammograms and flu shots.

Why not primary care?

He established a foundation, assembled a board of directors and hired an administrator. He found a federal program that assumes responsibility for malpractice claims against volunteer practitioners at free clinics.

Now, there was only the small issue of an operating budget. The project started with about $350,000 in grants and another $100,000 in donations from businesses, charities, wealthy benefactors and the Archdiocese of Hartford.

Most of the money covers the cost of prescription drugs, radiology and lab tests, all provided free to Malta patients. Arrow Prescription Center, Collaborative Laboratory Services and the St. Francis Hospital and Medical Center radiology department provide these services at cut rates and bill the clinic directly.

But van Rooy asked people for more than money.

He needed their time.

The medical profession's generosity is a well-kept secret, van Rooy had noticed. Physicians regularly fly off to places such as Nicaragua and Africa to deliver free care. All he had to do was convince them that the need was just as great in the insurance capital of the world.

With the Airstream on permanent loan from St. Francis and a handful of doctors and nurses who answered his call, van Rooy's vision hit the street last July.

Cutting Costs

Kim Oaks grew up in West Simsbury assuming that when people are sick, they go to the doctor, simple as that.

The 17-year-old high school senior had been taking Spanish since first grade and aspired to become a speech pathologist. Although the announcement she spotted in the St. Bernard's Church bulletin was seeking doctors, she decided to see if she could help.

Her parents were a bit leery when their only daughter signed up to volunteer in Hartford's worst neighborhoods. But they also recognized the opportunity. They bought her a state-surplus Ford Taurus and she drives to the clinic after she's done with her honors-level physics, calculus and British literature classes at Northwest Catholic High School.

Oaks has plenty of company. The Malta clinic draws doctors taking days off from busy practices; nurses who give up vacation time; and homemakers who are not afraid to venture into the city wearing designer pants suits and multicarat diamond rings.

After almost a year, the clinic's volunteer roster has grown to include 10 physicians, two nurse practitioners, 11 nurses, one physician's assistant and countless non-medical volunteers including a group of Trinity College students who serve soup in the waiting room on Wednesdays and a mother of three who does paperwork from home.

With so little overhead, the cost per patient visit - including all tests and medication - is about $130, far less than a comparable visit that would cost $240 at a hospital emergency room. And at the emergency room or even a public health clinic, patients with no insurance are expected to pay.

One patient who got an X-ray at a hospital clinic left with an $1,800 bill. He's now getting care through Malta, but still has no way to pay his debt.

Treating no more than 70 patients a week and relying on good will, Malta's organizers acknowledge that they will never solve the nation's health care ills. But Alan Sager, a professor of health policy at Boston University, says they nonetheless might be on to something.

This year, the United States will spend $2.3 trillion dollars on health care, half of which, Sager says, is wasted. Most of the waste can be found in four areas: financial and legal incentives for doctors to over-test and over-treat; piles of duplicate paperwork; overpriced medication; and fraud and theft.

"Doctors are paid by the visit, by the slice, by the stitch and the scan," Sager says. "You have a huge incentive to do more."

For doctors at Malta, the only incentive is to do what they can.

And, by focusing on primary care in the poorest communities, Malta's founders say they can save lives and money.

Chronic diseases, including heart disease, stroke, high blood pressure and diabetes, are among the most prevalent, costly, and preventable of all health problems. Seven of every 10 people who die in the United States each year - more than 1.7 million people - die of a chronic disease.

Yet in cities such as Hartford, many of those diseases go unnoticed and untreated.

Dr. Joseph Breton emerges from the cubicle behind the camper's steering wheel, where a woman from Mexico sits on a vinyl bench. The tiny space, one of two examining rooms, is crowded as Breton tries to examine her and Felix Ortiz hovers over his shoulder, translating.

The woman says she has diabetes and has been feeling a little tired. Breton does not understand a word of Spanish, but knows her symptoms are screaming blood sugar out of control. He asks a nurse to do a glucose test.

In Breton's Enfield office, where he shares a practice with his wife, the 43-year-old internist asks the nurses for a test and the test is done.

Here, he must be more patient. It is this volunteer nurse's first day, and she rummages through the camper's oak cabinets before finding a home glucose test kit.

The patient's blood sugar registers 500 - almost five times higher than it should be.

"That's why she's feeling awful," Breton says.

The woman says she has run out of medicine and has been trying to get it from Mexico, where it's cheaper. Breton bristles at the backwardness of this equation. With no way to pay for the drugs, the woman is at risk for a heart attack, stroke, blindness or kidney failure - any of which could land her in the emergency room.

With the medication, he says, she could be healthy - and the nation's health care system could save a fortune.

"For the next 10 years if it costs $15,000 to give her medication," Breton figures, "that's about the cost of two days in the hospital."

But there are also limitations.

On another day in the clinic, a woman bringing her father in for care presses a lime-green post-it note into Dr. Michael Collins' palm.

"He has cancer, he doesn't know it," it says. "Please don't say the word cancer."

Collins, wearing sensible shoes, slacks and a pullover, takes Monday afternoons off from his busy Manchester internal medicine practice to volunteer at the mobile clinic.

Collins massages a lump the size of a large orange that protrudes from the left side of the patient's neck. He had a biopsy and an X-ray about a month earlier and now he is having trouble swallowing. The man's daughter brought his test results concealed in an envelope.

Collins can do nothing but send the man back to the hospital where his cancer was diagnosed. The Malta House specializes in primary care and has no way to pay for more complicated treatments, such as surgery.

He suggests that the daughter, who speaks good English, try to negotiate a payment plan with the hospital's finance office.

"That man has a huge tumor in his neck, I don't know if the hospital will do surgery," Collins says later. "It makes you feel helpless."

Feeling Better

Even with the promise of free care, no questions asked, it is desperation that draws most patients to the clinic.

Gary, 56, is a week out of prison and out of his medicine for high blood pressure, high cholesterol, heartburn and gout. His parole officer sent him.

A 40-ish laborer from Brazil comes with a blinding headache, terrified that his high blood pressure is about to kill him, the way it killed two brothers and his father when they were his age.

Stacey Ayala, 21, is hoping to get her 4-year-old son, Amani, up to date on his immunizations so he can go to preschool. It's rare to see children at the clinic because almost all low-income children are eligible for HUSKY, the state's Medicaid plan.

But HUSKY coverage for Amani and 2-year-old Asia has lapsed, and their mother is stuck in the web of new federal regulations that require applicants to produce a certified birth certificate to renew their coverage.

Ayala said the birth certificates, along with just about everything else the family owns, were left behind when Ayala's boyfriend kicked her out of his apartment. She says they have been living in a shelter for a month and each time she goes to a social service office for help, they tell her to come back the next day.

Tough times brought Genaro Sepulveda to Malta as well.

At 49, Sepulveda was laid off last September from his job managing residential and office properties. He was collecting $465 a week from unemployment and it would have cost $480 a month to keep his health insurance until he found another job. With a mortgage on his New Britain home, car payments and student loans, he had to make a choice.

Everything was OK until he got a cough that would not quit. A friend recommended the Malta clinic. And there he was one day, sitting on a folding chair filling out his medical history: married, one grown son, college educated, unemployed.

"It's shameful," he says. "This is the kind of thing that doesn't hit you until you go through it."

While he was waiting in the basement of St. Augustine's Church to see the doctor, Sepulveda overheard a volunteer translator struggling to interpret a Spanish word a patient was using to describe a symptom. When the translator used the wrong word, Sepulveda jumped in.

Always on the lookout for fresh help, the clinic director, Barbara Ruel, invited him to fill his free time as a translator until he lands a job. So along with a prescription for cough syrup, he left the clinic with a new assignment.

Weeks after that initial visit, Sepulveda is standing in leather loafers and dressed for office work in pressed slacks and a starched white shirt beneath a Navy blazer as he interprets for Juana - who has returned two weeks after her first visit.

She is perched on a folding chair when Stephen Sullivan, a 20-year-old Trinity College sophomore from Ohio offers her a bowl of chicken coconut soup prepared at the college dining hall.

Juana puts a spoonful to her lips, scowls and pushes the paper bowl away.

"Salt, mucho!" she exclaims.

A month ago, Juana says, she had no idea she had high blood pressure. She had no idea that too much salt could kill her. She didn't know about the diabetes either, until she had the stroke.

Harris had sent her for blood tests and she started taking medication. For the first time in years, she was taking control of her health.

Harris checks Juana's blood pressure and it's still a little high, 154/102. He'll write a new prescription and see her again in two weeks.

As she gets ready to leave, van Rooy pops into the church basement on what have become his regular rounds. Ruel quickly tells van Rooy Juana's story and Juana hugs Ruel to express her gratitude. "That is what we should be doing," van Rooy says, satisfied. "Taking care of people who fall through the cracks."

The Malta House of Care clinic is open from 1 to 5 p.m. Mondays at Sacred Heart Church, 49 Winthrop St.; Wednesdays at St. Peter's Church, 160 Main St.; and Thursdays at St. Augustine's Church, 10 Campfield Ave. For more information, call 860-714-1415.