A Shadow Medical Safety Net, Stretched to the Limit
A Shadow Medical Safety Net, Stretched to the Limit
In March, New York City began moving homeless shelter residents believed to have Covid-19 to “isolation units” within existing facilities. In April, it began using the city’s inventory of empty hotels, which were supposed to be for residents who weren’t yet sick enough to need hospital care. There was plenty of space available; the problem was how to staff it. For one hotel, the city contracted with Housing Works, a nonprofit focused on homelessness and H.I.V./AIDS. Housing Works brought in Callen-Lorde Community Health Center, which serves L.G.B.T.Q. New Yorkers. Callen-Lorde’s staff learned the hotel’s exact location, in Queens, late in the morning on Friday, April 3. There were 133 rooms, expected to hold more than 170 patients. They had only a few hours to get the place ready: The first patients would begin arriving that night.
The chief nursing officer of Callen-Lorde, a 38-year-old named Anthony Fortenberry, already had his hands full. He had spent the first weeks of the coronavirus pandemic trying to build a system to track the center’s thousands of patients, even as their care shifted from Callen-Lorde’s offices in the Manhattan neighborhood of Chelsea to the internet. The center’s origins trace back to the era following the Stonewall uprising, when a single doctor offered free health care, including methadone treatment, contraception and pregnancy counseling, from a small clinic on St. Marks Place in the city’s East Village. Today the center has four different sites, with 66,000 square feet of offices, and serves some 20,000 people a year. One-quarter are H.I.V.-positive, and could be at greater risk of illness or death from Covid-19. Many deal with issues surrounding mental health, substance abuse or lack of housing. A number were shut out from traditional medical care because they lacked insurance; others decided to self-exile from a medical system that treated their sexual identities with confusion or even scorn.
“I would tell them that they needed to go to the E.R.,” Fortenberry recalls of some transgender patients. “They would say: ‘Absolutely not. I would rather die than be misgendered or mistreated. It is not worth going through the trauma.’” According to a 2017 poll, 18 percent of L.G.B.T.Q. Americans say that fear of discrimination has kept them from seeking medical care.
In March, at least, much of Fortenberry’s work had involved doing everything possible to keep H.I.V.-positive patients away from hospital emergency rooms, where those who didn’t already have the coronavirus would be at the greatest risk of contracting it. Callen-Lorde’s main storefront clinic in Chelsea had cut back on staff, but Fortenberry continued to ride the subway from his home in Queens and work out of his windowless basement office, and a handful of other staff members remained on-site to advise patients who thought they might have Covid-19, or those with mental-health or substance-abuse issues who weren’t yet aware that the city was in the process of shutting down. Hundreds of patients were calling in each day to ask about Covid-19-like symptoms; over the weekend of March 28, more than 700 voice mail messages were left in what Fortenberry calls “a run on the pharmacy,” as patients rushed to stock up on medication in case the quarantine disrupted supplies. Some patients who were being treated for H.I.V. or gender transition were living with family members or roommates who were unaware — they needed to make arrangements to pick up medication at Callen-Lorde’s pharmacy or have it discreetly delivered to their homes.
Callen-Lorde continued monitoring patients through telemedicine, often laboriously chasing them down by phone and email. The center kept a close eye on its dwindling supplies of gloves, masks, gowns and hand sanitizer. Some staff members started to get sick; Fortenberry set up a team to monitor them in quarantine and decide when it was safe to return.
This wasn’t the first time the center had dealt with the possibility of a pandemic: After a 2012 outbreak of fungal meningitis among gay men, Callen-Lorde helped other area health centers come up with protocols for dealing with outbreaks of disease. Two years later, it had a dry run when a doctor returned to New York from Guinea carrying the Ebola virus. Fortenberry already had a rough playbook for Covid-19 — at least until April, when the city started moving people into its hotels and his job was transformed.
Minutes after he learned the address of the new quarantine hotel, Fortenberry called an Uber, threw whatever supplies and equipment he could into the trunk and rode to Queens. By the end of the day, his staff had filled the hotel’s basement gym with masks, gloves and gowns. They scoured nearby bodegas for more acetaminophen and ibuprofen. The staff turned the breakfast area into a triage space, with a row of tables serving as a makeshift barrier. Fortenberry had ordered a printer, scanner and filing cabinet for basic record-keeping, but these had not arrived yet. Handwritten files on the hotel’s first two dozen occupants piled up on a conference table in the business center.
One of the first patients arrived in a wheelchair pushed by paramedics. He was middle-aged and homeless, suffering from diabetes and advanced kidney disease. Under normal circumstances, any American in his condition would have been situated in a hospital intensive-care unit, or hospice. His blood oxygen was dangerously low, aggravating problems caused by his diabetes and kidney disease. He was, Fortenberry told me by phone that weekend, “actively dying.” “This patient is not going to make it,” he said. “Where that is going to happen is the question.”
Many of the patients in that first wave were in worse shape than Fortenberry was led to expect. The plan had been for the hotel to house “low-acuity” patients who were not at immediate risk of dying in order to free up hospital beds as the virus swamped New York. But as the crisis approached its peak, the meaning of “low-acuity” seemed to shift. Having stood up the equivalent of a field hospital in 24 hours, Fortenberry quickly realized he’d be receiving patients who were far more ill than his staff was equipped to deal with.
At the same time, the crisis was creating a third problem for Fortenberry: his budget. Even as the pandemic multiplied the needs of Callen-Lorde patients, the drop in face-to-face consultations was slowing the flow of Medicaid reimbursements to a trickle. The center applied for a loan from the federal government under the Paycheck Protection Program, but received no feedback beyond an acknowledgment that the application had been received. In April, senior staff members began discussions about the possibility that they would have to furlough staff. Outside New York, hundreds of other community health centers were grappling with similar problems — a spike in the need for urgent medical care for their patients, coupled with a sudden shortfall in government funding. The virus was doing more than filling up hospital I.C.U.s beyond capacity; it was stretching the resources of the country’s shadow medical safety net, the one that reaches patients whose location, economic circumstances or existing health status already puts them at greater risk.
Part of Fortenberry’s job, as he saw it, was compartmentalizing — filtering out his own fears so as not to pass them on to colleagues or patients. Before joining Callen-Lorde, he worked as a nurse at a Greenwich Village intensive-care unit, and before that, at a Level 1 trauma center in the Bronx. But the equanimity he absorbed from these experiences was now being put to the test. “I think it’s very important for our staff to have the impression that I have everything under control and that everything is going to be OK,” he said. “The default is panic. Especially in this kind of situation, where we’re in way over our heads. I think the last thing that everyone needs from me is to show uncertainty. But deep down inside, I’m, you know” — he laughed softly — “it’s an untenable disaster.”
Callen-Lorde is one node in a network of more than 1,000 community health centers, or C.H.C.s, spread across the nation. By law, C.H.C.s work with “medically unserved” populations and receive federal funding from the Department of Health and Human Services. There are centers that specialize in treating farmworkers, non-English-speaking immigrants, public-housing residents and rural communities. They work at the nexus of medicine and social care, with dedicated intake workers who help the undocumented or the uninsured navigate health care bureaucracy before they have a problem that sends them to the emergency room. Many patients are unable to wall themselves off from infection because they take public transportation to subsistence jobs in agriculture, sanitation or front-line retail, and it is these patients — the same ones who continue to arrive at the Queens hotel — who would die in disproportionate numbers if policymakers decided to pare back social-distancing measures. Attention and resources continue to flow to hospitals, the first line of defense against the virus. But the nationwide safety net of C.H.C.s beneath them is being stretched to its limit.
The first C.H.C.s were founded by civil rights activists in the mid-1960s and began receiving federal funding as part of President Lyndon B. Johnson’s Great Society program. Today they treat nearly 30 million patients each year, two-thirds of whom live below the federal poverty line. One of the oldest and best-known centers, Eula Hall Health Center (previously known as the Mud Creek Clinic), serves families of coal miners in the Kentucky Appalachians. The federal government has used such C.H.C.s to screen coal miners for black lung and fund specific subsidiary programs to make sure that the homeless, public-housing residents and farmworkers have adequate health care. During the 2012 meningitis outbreak, the City of New York used Callen-Lorde to reach gay men, who were especially at risk, and provide free vaccinations.
Beyond their humanitarian value, these programs save the health care system money by keeping uninsured patients healthy, as opposed to waiting for them to get sick enough to call 911 or show up in an emergency room. But the immediate needs faced by C.H.C.s are often so great that even long-established organizations exist on a hand-to-mouth basis, plowing whatever funding they receive immediately back into payroll and patient care. “Many C.H.C.s don’t keep profits in a bank account,” says the University of Chicago’s Dr. Marshall Chin, who researches health disparities. “They’re already under tremendous strain from the needs of their patients.”
For many C.H.C.s, dealing with the immediate impact of Covid-19 is drawing down resources at the very moment they need to be making preparations for a more extended public-health crisis. One scenario is millions of newly vulnerable workers crowding patient rolls, even as the centers struggle to maintain their funding. “It’s the double whammy of the medical hit, and then the economic one,” Chin says. “If you’re a front-line worker, you have to drive that bus or that Uber. You can’t socially distance because your housing is too crowded. Then, if you get sick, you can’t get into your C.H.C. because the centers are letting go of folks.” The U.S. health care system suffers from a chronically under-resourced safety net. “So when something like Covid hits,” Chin says, “you have a lot of people who get hurt.”
For Albany, Ga., the metro area with the country’s second-highest number of deaths per capita from Covid-19, the rural outskirts’ local C.H.C. is Albany Area Primary Health Care. The center has been conducting much of its practice through telemedicine. Often this entails calling up patients who have missed appointments and walking them through how to download and use the right app. “I’ve almost become a telemarketer,” says Dr. Jim Hotz, the center’s founder. “People do not want to come into the office.”
Hotz himself found out he had prostate cancer earlier this year, but postponed definitive treatment after regional hospitals put the type of surgery he needed on hold due to the pandemic. At A.A.P.H.C., the number of patient walk-ins, too, has fallen by about half. Only 40 percent of the center’s patients have smartphones. “The people who are poor, rural and don’t have broadband are our highest-risk population,” he says. “And those are the ones we are least incentivized to take care of.” Much of the Covid-19-related work that the center has been doing spills over from health care into social work, like counseling the grieving wife of a terminally ill man who had been discharged from the hospital to a hospice, which had no staff left to take care of him at home. For the 45 minutes that Hotz spent talking her through her grief by phone, the center got a reimbursement of $13.
Elsewhere, Dr. Laurie Zephyrin of the Commonwealth Fund has seen pregnant women forgoing prenatal care, and chronic conditions like heart disease and kidney disease left untreated. “It’s not that all of a sudden people are cured,” she said. “It’s that they’re not going to the doctor. People are losing insurance coverage, losing their jobs. There needs to be some focused investment on our health care infrastructure and policies for universal health care so we can provide for people as we bounce back.”
Social distancing may be especially hard on the L.G.B.T.Q. community, particularly younger people who are estranged from their families. In April, the Trevor Project, another nonprofit, published a white paper outlining the risks related to Covid-19 for L.G.B.T.Q. youth. Considerable research already indicates that this group is at greater risk of mental health disorders and suicide; now they are being deprived of the community spaces where they do feel supported. The number of L.G.B.T.Q. youth reaching out to the Trevor Project’s hotlines has at times more than doubled since the crisis began. “We’re seeing a lot of patients with mental health issues because of an oversaturation of news and fear,” Fortenberry said. “This is already a particularly vulnerable population at baseline. When these kinds of events happen, there can be relapses into substance abuse as well. People tend not to be able to take care of themselves as they normally would in these kinds of crises.”
It will be years before anyone is able to tally up the damage Covid-19 is inflicting on the populations that community health centers serve, especially when one accounts for the secondary costs to those who may never even contract the disease. The problems already emerging — in rural access to telemedicine, in access to medication for chronic conditions, in the dangerous isolation of L.G.B.T.Q. youth — could be the first indications of a much broader, secondary health crisis affecting treatment for the diverse range of maladies, from opioid addiction to obesity to chronic depression, that are commonly addressed by C.H.C.s. As part of the current stimulus package, community health centers stand to receive some share of a $50 billion line item aimed at Medicare-funded providers. But that money, according to the Department of Health and Human Services, will be divided up based on existing revenue, and it remains unclear whether any money will be specifically dedicated to dealing with the crisis’s secondary damage. Eventually, as epidemiologists compare mortality rates for 2020 and 2021 with previous years, the deaths caused by this lack of access to basic medical care may be lumped in with Covid-19 itself, despite a number of them having been more preventable.
As the geography of the virus’s impact continues to spread from New York to the rest of the country, more C.H.C.s will likely feel the same strains Callen-Lorde has as they try to balance their commitments to existing patients with the surging demand for care. Yet even as C.H.C.s are called upon to do more, the federal government is asking them to make do with less. Most of the centers’ funding comes from Medicaid, which compensates them for remote patient visits at a small fraction of the rate of live visits. The average reimbursement is $12 or $13, according to Dr. Ron Yee, chief medical officer of the National Association of Community Health Centers; there are likely millions of patients, meanwhile, who don’t even possess the technology to connect with their C.H.C.s remotely. “Once we get through the surge, we could have more problems later on if we are struggling to keep up with our patients,” Yee told me. “We’re going to have to catch up on our chronic care, and kids who need vaccines. Our population of patients age 65 and up had already been increasing at a higher rate. It’s even more critical that we stay on top of their care now.”
In one of our first conversations, Fortenberry told me he planned on spending a day or two at the hotel, setting things up, until the regular staff settled into a rhythm. Two weeks later, he found himself still showing up most days at 8 in the morning and staying until 8:30 or 9 at night. Working behind a mask and goggles, he did what he could to form bonds, quickly and at scale, with individual patients. Sometimes he’d tell his Covid-19 patients that he was smiling behind his mask, though that may already have been clear from his large, almond-shaped eyes.
The rooms at the hotel lacked IVs, heart monitors, oxygen masks and resuscitation equipment. By the second week of April, the site held about 150 patients. With five to seven medical staff at any given moment, that meant that medical check-ins took place around four times per day. But “if you’re sitting in a hotel room and having trouble breathing, I don’t want you to not call me,” Fortenberry said. “Someone who is otherwise healthy can take a turn for the worse really quickly. So it’s important that you feel comfortable calling. I want you to err on the side of caution.” That day he had met a woman in her early 20s, most likely pregnant, who was living in a women’s shelter because of a violent partner. She had asthma, a high fever and pneumonia, and was awaiting the results of a Covid-19 test. Fortenberry delivered all of her meals personally and asked about her favorite foods. “It’s hard because you can’t hold someone’s hand,” he said. “You’re all gloved up.” He said that he had sympathy for those who chose to walk out of the hotel. “People get stir-crazy,” he said. “Anyone would. Imagine you’re sick and you get stuck in a hotel room and you’re not allowed to leave for an entire week. You can only watch so much TV.”
Back at home, he stayed up attending Zoom meetings and catching up on email. There was just too much to be done. On the second or third day, the hotel’s staff engineer walked off the job, along with most of the cleaning staff. They took access to room keys and cleaning supplies along with them. The city was able to find replacements within 24 hours, but there were still only enough hands to clean rooms during changes between patients. During a patient’s stay, the job of changing sheets, cleaning toilets and providing for daily necessities like soap and toothpaste fell to the doctors and nurses on Fortenberry’s staff. The staff’s medical gowns and N95 masks were worn until they became visibly soiled. The risks to their own health were significant, which was part of why Fortenberry stayed. “I don’t want to ask them to do anything that I wouldn’t do myself,” he told me one evening during the third week of April. “Morale has been harder to maintain the longer we have to keep this up. The adrenaline has worn off.”
It was our seventh evening phone call. For the first time, he sounded tired. “It’s been increasingly difficult to compartmentalize emotionally,” he said. Over the previous weekend, another homeless patient had come in who was suffering from diabetes, kidney disease and symptoms of Covid-19. He was on dialysis, but had grown confused and refused treatment for several days. He was close enough to death for Fortenberry to call 911. The paramedics who arrived refused to take him to the emergency room. “You don’t know what’s happening in the E.R. right now,” one of them told Fortenberry. “People are dying in the hallway. We are beyond beyond capacity.” Fortenberry reminded them that the hotel had no resuscitation equipment and that the patient was “decompensating,” his vital systems failing. “They have to decompensate further before we can take them,” the paramedic said. So Fortenberry waited another 24 hours. The patient got worse. Fortenberry called 911 again. This time, they took him.
Many of the patients coming into the hotel had not been tested at the hospital, but were assumed to have Covid-19 because of their exposure and symptoms. This made Fortenberry skeptical about claims by Gov. Andrew M. Cuomo and others that the crisis was about to reach its peak. “They’re not testing people who I know to be sick,” he said. “Maybe that’s being accounted for in these official projections, but it’s hard for me to reconcile.” By late April, what he saw on the ground had begun to reflect the story contained in the official statistics. For now, the crisis was slowing down.
In New York State, Callen-Lorde and other C.H.C.s will likely suffer from $2.5 billion in cuts proposed by the governor’s Medicaid Redesign Team. After the center’s cash flow plummeted in March, Callen-Lorde’s senior staff members took pay cuts ranging from 10 to 15 percent, and management warned that there could be furloughs and layoffs ahead. Callen-Lorde received less than $600,000 from the federal stimulus bill, enough for one week of payroll. It never heard back about its initial loan application, made via a large commercial bank in New York. Loans for Shake Shack and Ruth’s Chris Steak House, meanwhile, were approved. (After a public outcry, both said they would return the loans.) “I’m infuriated,” Fortenberry said. “These are not small businesses. You would think there would be some prioritization of safety-net health care providers.”
Callen-Lorde’s staff was well aware of how thin the center’s resources were stretched. Several sent out calls for equipment and funding to their own networks. On Instagram, a doctor’s partner asked for donations of handmade gowns, and a few days later, a box showed up on her Park Slope doorstep. Inside were 17 handmade gowns mailed from Overland Park, Kan. When Fortenberry saw the gowns, “I went to the bathroom and just lost it,” he said. He had his staff try them on — they had been sewn from fabric he fondly described as “the most hideous 1970s floral-patterned sheets” — and take a group photo. The gowns were sewn by Jan Durham, a quilter and self-described “fabric hoarder” who searches for her quarry at thrift stores and estate sales. “I hope these will be of use, although I also wish they were not needed,” she wrote in an accompanying letter. “It just makes me furious that we’re sewing P.P.E. at home,” she told me by phone, a few days later. “I’m glad to do it, but we are a great nation. We should not have to rely on seamstresses in their homes to provide these critical things.”
In Queens, Fortenberry was troubled by a parallel set of worries. Late in April, there was still no word back from the bank. Without a loan, Callen-Lorde would not be able to make payroll, and it would be up to Fortenberry to decide who among the medical staff was essential and who was not. “That’s an impossible thing to ask me to do,” he said. It was the first time that I had heard him complain.
As with the gowns, personal relationships compensated for the failings of the official infrastructure. A member of Callen-Lorde’s staff had gone to college with someone who later became the chief loan officer at a small community bank in the South Bronx. By April 27, the bank was able to process a $6 million loan, enough for six weeks of payroll.
“It was such a huge relief,” Fortenberry said. “I didn’t know how I was going to live with myself.” It was almost May, and Fortenberry was busy setting up a second hotel for the city, this one for homeless L.G.B.T.Q. youth believed to have contracted the virus. The flow of patients into the Queens hotel had slowed, allowing him to catch up on paperwork and sleep. “In the beginning I was on autopilot, just making it work,” he said. But the brief break hadn’t exactly left him reassured. “It’s almost more daunting,” he said, “to have more time to think about what’s actually happening.”