Failing Healt

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Gloria Acevedo fondly remembers working in a child health clinic in East Tremont during her summers off from her job as a school nurse. “It was totally free,” says Acevedo, now president of nurses Local 436, part of DC 37. “And you especially had a lot of young mothers that would use this as their primary care because they had nowhere to go, they didn’t have money. My gosh, I have a great letter from one of these young mothers, how this is how she learned to be a good parent. Besides giving immunizations and general health care for these children, the parents got parenting classes, nutrition, everything.”

But if state authorities allow the city to move ahead with its plans, one in five of the city’s child health clinics will close their doors for good. Officials at the city’s Health and Hospitals Corporation (HHC) want to shutter nine of them, as part of a bid to close 27 city-run health clinics citywide and save the agency $2 million in operating expenses.

The child health clinic closings will also let the agency duck out of over $2 million more in needed repairs and renovations on the children’s facilities, according to HHC senior vice president LaRay Brown. Faulty wiring, flooding and heating problems affect eight of the nine clinics slated for closing, most of them in city housing projects. Over the past two years those eight have already been temporarily closed, awaiting repairs and renovation. “In these eight clinics’ cases, the clients are being served in other locations, and the staff have been moved already to those locations,” explains Brown. Under HHC’s plan, the temporary reroutings would become permanent.

Originally established in the early 1900s as “clean milk stations” that passed out free pasteurized milk to combat infant mortality, the child health clinics also helped quell diphtheria, whooping cough and tetanus via mass immunizations. Their hallmark has been counseling and education, with treatment services added in the 1970s.

Now, HHC is scrambling to take care of its bottom line. With Medicaid revenue dropping, state subsidies drying up and outpatient care increasingly hard to fund, HHC loses money on its clinics. In that light, the relatively small child health clinics–staffed by one doctor, one nurse and support staff–don’t offer economies of scale. They show some of the lowest utilization rates of the city’s clinics; the nine slated for closure had on average 3,300 visits in 1999. “These are tiny clinics that in this era are not the kind of clinics that most people want to come to,” says Brown. Many who do come are uninsured.

But if child health clinics are small, HHC itself has helped to shrink them, charges Dr. Katherine Lobach. A clinical professor of pediatrics at Montefiore Medical Center, she oversaw the child health clinics for a decade, first at the Department of Health and then under HHC, after the clinics were transferred to the hospitals agency’s oversight in 1994. Says Lobach, “It’s been clear since they were transferred to HHC that many of them would sort of be left to hang out to dry.”

Under Lobach’s management at HHC, counseling and education remained top priorities, medicines and lab supplies flowed freely to the clinics, and the agency aggressively recruited public health-oriented staff. But HHC eliminated Lobach’s unit in 1998, the year the agency decentralized its facilities into six regional networks headed up by hospitals.

Decentralization was the “final blow,” says Lobach. Now, some clinics have a tough time getting the medicines they need from busy hospital pharmacists, and clinicians are often juggled from facility to facility, so kids can’t stick with a particular doctor.

Drawing people to the clinics has taken a backseat as well. Advocates charge HHC has neglected to mount promotional efforts that could boost their patient numbers. Until the 1970s, integrated linkages across the public system meant all new moms were referred to the child health clinics by public hospitals or field nurses. Today, there are few such connections, and no outreach aside from some community fairs. Signage outside the clinics is poor or nonexistent. It’s even hard to find a working phone number for the clinics, as Hunter College students enrolled in a community-organizing course found out this spring. Armed with survey questions for child health clinic staff regarding clinic utilization, the students couldn’t get through to 40 percent of the phone numbers they tried. Phones rang and rang, or worse. “They were either closed, or there were disconnection notices, and not really any forwarding number,” according to senior Caroline Budhan.

While there’s little effort to pull in new patients, the clinic closings have already been shrinking the rolls of existing patients. When the Forest Houses Health Clinic in the South Bronx closed for repairs in 1998, patients and staff were rerouted to the Melrose Houses Clinic, a mile to the southwest. But only a third of the kids from Forest have ever showed up at Melrose for care, estimates one Melrose staffer who asked to remain anonymous. The new traveling distance–which could require two buses with small kids or in bad weather–is the prime reason that fewer showed up than expected. Unlike Forest residents, “the parents who live here at Melrose, they can just say, ‘I’ll be down in 5 minutes,’ and for sure they’ll be here,” the staffer explains.

With the high asthma rates plaguing the South Bronx and the city, Dr. David Evans of the Columbia School of Public Health agrees the extra distance is “a step backward.” New data stemming from a recent multimillion-dollar collaborative project with the child health centers showed that when staff are trained to better manage kids’ asthma, it helps protect kids’ health and save HHC money. “People did make fewer ER visits and more visits to local centers for treatment of acute episodes of asthma,” says Evans. “They were getting treatment from people who knew them and were providing their ongoing care.”

Getting the clinics reinstated may well require City Council members and other political leaders to fight for “their” clinics and even fund repairs out of their own budgets. That’s how Manhattanville, also temporarily closed down, stayed off the hit list: through advocacy by Councilmember Stanley Michels and a million-dollar donation by the Manhattan borough president’s office.

For Pedro Espada, a council health committee member whose district includes the now-closed John Mitchell Houses Clinic, the best solution is the most obvious: more money for HHC. “They always ask for zero budgetary dollars, zero tax levy dollars,” says Espada of the agency’s annual requests to the council. “It’s almost impossible for an organization that’s chartered to take care of all the indigent care in the city of New York to be able to afford it.”

Julie Hantman is a Manhattan-based health writer

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