Volunteers Plug Homeless Health Care Gap

Harney Cordua, a retired San Diego doctor, has a simple reason for volunteering his services on Wednesdays at the Joan Kroc/St. Vincent de Paul health clinic that provides basic medical care to homeless men, women and children.

“We see the people who are down and out,” Cordua said. “People get into some weird situations. Sometimes they fall so far between the cracks that you can’t see them.”

That was the case with an out-of-work and homeless truck driver who needed care for a badly damaged jaw. Government programs ensured that the trucker eventually would get care--but busy medical specialists who provide care through county and state entitlement programs were unable to treat the man for several weeks.

Cordua provided primary care for the trucker’s wounds and turned the man over to a social worker who “knows how to kick shins and get action.” Within minutes, the clinic had located a doctor who would voluntarily treat the man within a day.

“That’s what makes this job really worthwhile,” Cordua said. “We really pulled that one out of the hat.”

A growing number of San Diego-area doctors are heeding the call to treat the poor and sick for free. A recent San Diego County Medical Society position paper urged physicians to volunteer to help the homeless, in the face of worsening cutbacks of government-funded medical care programs.

But to some retired doctors, this supposedly new trend simply marks a return to the days when giving services to the poor was a basic part of being a doctor.

John Bishop, a retired San Diego pediatrician, volunteers at St. Vincent de Paul’s clinic partly to keep his medical license current. The clinic’s patients also give him an opportunity to practice his Spanish.

But Bishop also views the clinic as a good way to fulfill his obligation to provide community service.

“When I started out (in medicine) everyone volunteered,” Bishop said. “Everybody did their part to pick up the slack.”

Another retired physician, Frank Ditraglia, blames well-meaning government programs for getting doctors out of the volunteer habit.

“During the 1950s, we all volunteered,” said Ditraglia, who volunteers at the St. Vincent’s clinic. “The indigent, the homeless, they were all cared for by volunteer doctors. And, if you didn’t do it, your colleagues shamed you into doing it.”

“What killed (volunteerism) was the Great Society,” Ditraglia said. “Suddenly there were bucks for Medi-Cal and Medicare. Doctors started getting paid for it.”

With health-care costs skyrocketing and government funding on the decline, doctors have “gone the full circle . . . we’re back to having volunteers pick up the slack,” Bishop said.

Older doctors and nurses who will volunteer their time--or work at lower-than-market rates--represent “an absolute gold mine” for counties struggling to provide adequate care for the medically indigent, said Paul Simms, deputy director of San Diego County’s Physical Health Services department.

Federal and state regulators seem unlikely to bolster indigent health care, Simms said, “so maybe we have to start going back to some more fundamental values . . . when people (occasionally) gave half a day to the county hospital.”

But, although Simms and other health-care observers applauded volunteer efforts, they caution that voluntarism alone won’t solve the indigent population’s health-care crisis.

“It’s a stopgap measure,” said Stephen Shubert, executive director of the San Diego Council of Community Clinics, whose members provide primary medical care for many of San Diego County’s underinsured and uninsured residents.

“Sometimes you can get a volunteer program that is very successful in one area,” Shubert said. “But the problem is so massive that voluntarism alone really can’t deal with it. It’s simply not a universal solution. I’d never say anything bad about volunteer efforts, but I’d merely point out that it’s not the final solution.”

Access to affordable health care is a growing problem in San Diego County, where an estimated 600,000 people are uninsured or underinsured.

Lack of money is the most common reason that the homeless fail to seek medical care, according to a recent survey that San Diego-based consultants Brenda Hotchkiss and Shimon Camiel conducted for the San Diego Community Healthcare Alliance, a nonprofit group in San Diego.

Nearly 30% of homeless people interviewed during the survey cited money troubles as the primary reason for not seeking care. Inability to get to clinics was cited by 13% of the respondents. Just 20% of those interviewed said that finding medical care was not a problem, Camiel said.

The Hospital Council of San Diego and Imperial Counties, after studying care options available to the indigent, gave San Diego County a “D” grade.

“We are well on the way to failing to meet the access to medical care needs of San Diegans,” said council President James Lott.

The homeless can seek treatment by staff doctors at community clinics, but government-funded health-care programs don’t always reimburse clinics that care for indigent patients.

“People still call us ‘free clinics,’ but I have to reiterate that we’re not free,” said M. Jean Serafy, director of the five state-licensed community clinics operated by Episcopal Community Services in San Diego. Serafy said her clinics turn away patients only if a doctor is not available to provide treatment, but “quality medical care costs money, and we can’t do it cheaply.”

The homeless often go without primary care, however, because entitlement programs such as Medi-Cal and County Medical Services are designed for health problems that are life-threatening, potentially disabling or that cause severe pain and suffering.

One program, the Healthcare for the Homeless project, does reimburse community clinics for basic health care given to the homeless. During the fiscal year ended Nov. 30, 1988, the program paid for 11,888 visits by 4,000 people. During the first six months of the fiscal year ended Nov. 30, 1989, the program covered 8,119 visits by 2,808 patients.

The project, with the Logan Heights Family Health Center as the lead agency, has an annual budget of $1.3 million, including federal funds, private donations and in-kind services provided by participating clinics.

But the Healthcare for the Homeless project, like voluntarism, is only a partial solution to the medical needs of the homeless, said Logan Heights center spokeswoman Karen McCabe.

“It’s no surprise that those who are really left out of the system--the working and non-working poor who don’t even have a house--have the worst problems and the least potential for getting treatment,” said Frank Landerville, project director of the Regional Task Force on the Homeless.

The homeless “are usually the toughest group . . . for health professionals to deal with,” Landerville said. In addition to the needs for basic medical care, some of the homeless have untreated mental illnesses or physical problems linked to drug and alcohol abuse, Landerville said.

When it comes to basic health-care needs, homeless San Diegans suffer from the same ailments that dog San Diegans with medical insurance plans, said Dr. Lorin Holst, the medical director and only paid doctor at the St. Vincent de Paul clinic.

But the homeless usually are slower to seek medical care because they are more concerned with finding shelter and food, Holst said. As a result, simple, treatable illnesses are exacerbated by time and harsh living conditions.

Simple chest colds give way to pneumonia and bronchitis, rashes lead to severe infections, and muscular problems evolve into expensive and hard-to-treat conditions, Holst said. “They can end up losing a leg because they couldn’t get a simple $40 treatment,” Holst said.

The St. Vincent de Paul clinic sets no eligibility requirements for its patients because, “when you are sick you need care immediately,” Holst said. “Forms, bureaucracies, these are things that street people hate to deal with . . . they have a mistrust of all that kind of stuff.”

And, homeless people who conceivably could qualify for entitlement programs too often have “simply stopped paying attention to their health needs,” Landerville said. “It’s something that happens in the process of becoming homeless.”

“As time goes by, (their health) gets worse, they find themselves on the street and, in many cases, it’s been a long time since they’ve had adequate medical care,” Landerville said.

A case in point is the homeless man who sells homemade bamboo flutes on the street about a block from Landerville’s downtown office.

“He’s been diagnosed as having AIDS, and he obviously doesn’t have a lot of time left,” Landerville said. With that diagnosis, a San Diegan with health insurance might seek treatment for AIDS, Landerville said, but the man has a more immediate need: finding the money for a room so he can “take a bath and alleviate the pain of his skin infections.”

Three downtown San Diego operations--St. Vincent de Paul, Rachel’s Women’s Center and Life Ministries--rely almost solely upon volunteer doctors and nurses to treat the primary health-care needs of the homeless. But, as is the case with many charitable operations, it can be difficult to find enough volunteers.

Hoping to make volunteering easier, the San Diego Community Healthcare Alliance last year awarded $45,000 grant to an organization that attempts to place volunteer professionals at clinics that treat the homeless.

A pair of mailings to the county medical society’s 2,900 members has generated about 50 volunteers, according to Mary Carpenter, placement director for “Option San Diego.”

“It’s like anything else,” Carpenter said. “People pick up a piece of paper the first time and typically set it aside.” But Carpenter remains optimistic that more volunteers will be found.

Last September, the San Diego Gynecologic Society took the unusual step of asking its members to treat free at least one pregnant woman a month who would otherwise go without medical care because of a lack of funds or medical insurance. The new program was driven by the fact that San Diego County now has the state’s highest rate of no-care deliveries.

Similarly, Paul H. Coleman Jr., a Poway dentist, recently asked the county’s 1,600 dentists to provide a day’s worth of free dental care to the indigent on Feb. 14, Valentine’s Day. He was disappointed that just 30 offices agreed to take part in the project.

While the first year’s results “were not really impressive,” Coleman said that participating offices will on Feb. 14 provide nearly $100,000 in free dental care. Coleman believes that media coverage of the daylong event will promote a stronger response when the program is repeated in 1991.

Rachel’s Women’s Center, a downtown day center for homeless women that is operated by Catholic Charities, has attracted enough volunteer medical professionals to conduct a regular medical screening program. But without volunteers, “we wouldn’t do anything as far as medical services,” said Catholic Charities Director Sister Raymonda.

Sister Raymonda credited Dr. Carla Fox, a downtown internist, with recognizing the need for a screening program.

“This was the only place downtown where women gathered in large numbers,” Sister Raymonda said. Fox made the program a reality by finding more than a dozen doctors and nurses--including dentists, an ophthalmologist and a podiatrist--to provide volunteer services.

St. Vincent de Paul’s clinic, which relies totally upon volunteers, has compiled a list of about 50 medical professionals who regularly staff the clinic.

Each month, the clinic treats about 600 homeless men, women and children, Holst said.

Doctors at the St. Vincent’s clinic spend most of their day treating chest colds, bronchitis and pneumonia, medical director Holst said. During the winter, when temperatures plunge and the rain falls, San Diego’s street people are dogged by respiratory ailments.

The poor and homeless also are more likely to suffer muscular-skeletal problems--including sprained ankles, bad backs, wrist and shoulder injuries. Foot diseases, rashes and skin infections also are more common among the homeless, as are sexually transmitted diseases.

Volunteer Ivor Ankenbrandt, a Pacific Beach family practitioner, acknowledged that it is difficult to treat patients “when we hardly ever see the same patient twice.” And, when patients live on the street, patient compliance--a person’s ability or willingness to follow a physician’s directions--suffers, Ankenbrandt said.

“They can’t always go home and get a good night’s rest, because they don’t have a home,” Ankenbrandt said. And, “if they’re not hurting, they’re not going to come in” for follow-up treatment because they face more pressing problems.

Many of St. Vincent’s doctors were recruited by Ditraglia, a retired New Jersey family practitioner who moved to San Diego during the early 1980s. Ditraglia, who first heard of the clinic during a Sunday sermon, has done “everything short of standing on the corner with a bullhorn” to attract volunteers.

But his most successful tactic is to take potential volunteers on a “no-strings-attached tour” to see the facility and the needs of the people who go there for care.

“The key is to get them down here, and they’ll ultimately volunteer.”