At clinic, poverty magnifies health problems

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Rhonda Jones began seeing doctors at a Total Health Care clinic in West Baltimore in the 1970s, when she was pregnant.

Now 58, with a stroke added to her life's medical record, she still goes there. Public transportation brings her to appointments and she walks into the clinic with a cane.

"Even if you don't have insurance they'll help you," Jones said as she stood outside the Division Street location recently, wrapped in a light jacket. "One of the best community clinics in the city."

In Baltimore's poorer neighborhoods, where problems are plentiful and solutions scarce, Total Health Care strives to correct disparities in access and treatment long faced by people who struggle to get by.

Total Health Care is the result of the 1989 merger of West Baltimore Community Health Care Corporation and Constant Care Community Health Center, Inc.

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Its mission is to provide comprehensive, quality care to the low-income, medically underserved population. Its most recent filing with the Internal Revenue Service -- for 2013 -- shows 61 percent of Total Health Care's clients came for general medical treatment during 2012. Equal shares of 14.5 percent received either substance abuse treatment or help with mental illness and 10 percent needed dental services.

The poverty, substance abuse, and lingering trauma of street violence that shape the lives of many West Baltimore residents make the staff's work more challenging.

"One of the things that we do see in our patient population is that people lost the ability to dream," said Dr. Arethusa Stevens Kirk, Total Health Care's vice president of medical affairs.

All who enter must be served at Total Health Care, whether or not they can pay. The organization's designation as a federally qualified health center requires that, but it also brings federal subsidies to help pay for its work.

A nonprofit, Total Health Care operates nine centers in Baltimore, including three that serve some of the city's lowest-income neighborhoods. A 10th center, in Odenton, Maryland, opened last fall.

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Community health centers like Total Health Care have their roots in President Lyndon B. Johnson's War on Poverty legislation, specifically, the Economic Opportunity Act of 1964.

Then as now, doctors and community leaders saw how limited access to health care made lives worse for poor people. The 1991 Public Health Service Act made federally qualified health centers eligible for federal funding -- an incentive to provide medical care in low-income, medically underserved areas where most people did not have private health insurance.

Decades later, a demographic profile of Total Health Care's patients still demonstrates the weight of poverty and poor health in urban America:

Sixty-nine percent of Total Health Care's patients were covered by Medicaid or the Children's Health Insurance Program in 2014, both government-funded programs for the poor, according to the federal Health Resources and Services Administration. Life expectancy is about 68 years in the Upton/Druid Heights neighborhood where Total Health Care's Division Street center is located, according to 2013 data published by Baltimore Neighborhood Indicators Alliance. In Roland Park, an affluent neighborhood 6 miles away, it's more than 84 years. Up to 60 percent of Total Health Care's patients are so poor they live a subsistence, survival-based existence, said Dr. Janice Stevenson, a staff psychologist and vice president. Some patients have never gone to the beach or even Baltimore's famous Inner Harbor, she said.

When a reporter visited the Division Street location one morning, it was busy treating patients with problems ranging from urgent care needs to mental health counseling. Total Health Care's services also include adult primary care, pediatrics, obstetrics/gynecological, behavioral health services and early intervention HIV/AIDS treatment.

Individualized care plans are developed for patients and the staff coordinates the delivery of care, said Dr. Marcia Cort, Total Health Care's chief medical officer.

That means keeping tabs on patients through phone calls, friends, neighbors and visits from community health workers.

Public health statistics show poor people develop chronic illnesses at higher rates -- and at younger ages -- than people in affluent communities.

Total Health Care observes that frequently. "We see hypertension diagnosed at much earlier ages. We see diabetes diagnosed at much earlier ages," said Kirk, the medical affairs vice president. "We see people dying at much younger ages from complications of these diseases."

The tragedy is people often don't seek care early enough.

"Patients tend to present at a very late stage in their illness, which a lot of times could be very preventable," Cort said.

Mental health issues related to trauma are common and pose significant treatment problems, too, staff doctors say. Losing friends and family to violent deaths is not unusual in West Baltimore.

After Freddie Gray's death in police custody last year, violence spiked in Baltimore. The city ended the year with the year with 344 homicides -- the most ever per capita.

"There's lot of unresolved, highly complicated bereavement issues," said Stevenson, the psychologist. "On any given day … any given patient can present with eight to nine recent deaths … in the last six months."

Post-traumatic stress disorder and attention deficit hyperactivity disorder are the two most common mental health diagnoses at Total Health Care, according to doctors. But patients also experience depression, anxiety, mood disorders and substance abuse problems, Stevenson said.

Since its start in 1968, Total Health Care has grown to serve more than 37,000 patients annually with a staff of about 375 employees.

In the world of Total Health Care and its patients, "relationships really matter, and they matter deeply," said Kirk. "And the longer you're here, the longer you're going to have a loyalty."

Rhonda Jones, with four children and four grandchildren of her own now, is one of those loyal long-timers.

Lacking a car, Jones and her sister, Renita Matthews, who accompanies her, take a disability bus service to medical appointments.

"It's a nice clinic," Jones said outside the Division Street facility. "They're very good. As long as you treat them with respect, they treat you with respect."

Generations of families have stayed with Total Health Care, Kirk said, even traveling to its clinics from surrounding counties after relocating. She's seen patients go off to college, make honor roll and then become great parents.

Years go by, and they continue as patients.

"What keeps you here is that thought that if I work hard enough and care hard enough and we do our job well," Kirk said, "that we're going to transform this."

CNS reporters Brittany Britto, Carrie Snurr and Chris Cox contributed to this article.

This story is part of a reporting project of Kaiser Health News and University of Maryland's Philip Merrill College of Journalism, which operates Capital News Service.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

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