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Despite a good safety net system, St. Louis still struggles to get healthy

By Rachel Lippmann, St. Louis Public Radio


St. Louis – A DJ spun tunes on a hot summer Saturday as Shamika Haywood got her blood pressure checked in a booth at the Grace Hill Water Tower Health Center for the annual health fair.

Haywood, who started using Grace Hill's facilities 15 years ago, also brought her two children for free back-to-school physicals.

"It's a neighborhood clinic. I used to go when it was right there, the old one," she said, pointing to a nearby location, "and it was close to home, so it was walking distance."

Haywood is employed, and has life insurance through her job with a home health care agency. But health insurance is too expensive. During one of her regular check-ups at Grace Hill, a doctor found her acid reflux.

"Without the clinic, I probably would have went to the emergency room and had a high bill that I couldn't afford," she said laughing.

The Water Tower health center--along with 12 other federally qualified health centers in St. Louis--are set up to serve patients exactly like Haywood. The centers have to care for everyone, though they charge co-pays based on income levels. In exchange, FQHC's get reimbursed at a higher rate for Medicare and Medicaid, and are eligible for certain grants. And they are the source of primary care for a large number of St. Louis residents, said Alan Freeman, Grace Hill's CEO.

"Some would say that we compete with physicians and other services that are in private practice. By and large the areas that we serve are not areas where most private practitioners go to work or to set up practice," he said. "We serve a low income population."

Poverty, health and race are tightly linked in this city and have been for a century or more. In 1901, a black tuberculosis patient was three times more likely to die than a white patient. In 1944, the infant mortality rate among blacks was 6.5 percent, compared with 3.25 percent for whites.

Those numbers are still abysmal today. Infant mortality rates are almost three times higher for blacks than whites. A black person is three and a half times more likely to be infected with tuberculosis. Asthma, heart disease, and sexually transmitted diseases are at epidemic levels.

A 2004 study from the city's health department found the city's poorest ZIP code--which is 95 percent black--was also the unhealthiest. Dr. Will Ross, the associate dean for diversity at the Washington University School of Medicine, wasn't surprised when he saw the results.

"Getting adequate food. Staying safe. Paying the rent. These are competing priorities that sometimes will reduce the visit to something perfunctory," he said. Unhealthy people can't work, he added, which leaves them without the resources to get healthy, which leaves them without the ability to work.

But in more than two decades of work on minority health care, Ross found the problem ran deeper than chronic poverty.

"When the residents are so disempowered, so disengaged from the health system, they give up hope," he said. "Sometimes they just stop trying because they say well, I'm unhealthy, my parents are unhealthy, my mother's unhappy. You develop fatalism."

A big part of it, said James Kimmey, the president of the Missouri Foundation for Health, can be pegged to one date in history: August 17th, 1979. On that day, police in riot gear stood guard against a crowd of protesters as nurses and doctors transferred the last patients from Homer G. Phillips Hospital on the city's north side to St. Louis's other public hospital near Lafayette Square.

"Homer G. was really a matter of great pride in the African-American community," Kimmey said. "It was probably one of the two or three best training hospitals for African-American physicians in the country when they couldn't get into the residency programs at other hospitals in the country."

Homer G. was, for a while, one of only a few hospitals that served the black community. But when a court rejected segregation, and the city's population began to drop, the city could no longer afford to keep its two public hospitals open. Though it had better facilities than City #1, Homer G. ended up on the chopping block.

"That decision was made," Kimmey said. "There was a mayoral election. The mayor who has said he was going to do that was ousted by a candidate who said he would not close Homer G., who then closed Homer G. It was really a sociological disaster."

Kimmey's foundation is one of the largest provider of grants to non-profits who are working on health care in underserved areas. One serious area of focus, he said, is customer service. A 2003 study showed, among other things, that patients did not go back to FQHCs because they felt disrespected.

"We don't do a good job of customer service in the health care system," he said. "And customer service is very important. It's very important that people feel comfortable at the site of care, that they feel confident in the competence of the people that are providing that care." Similar studies, he said, show that minority populations want providers from their community.

At Washington University Medical School, that job falls to Will Ross. But, he said, it'll take more to regain the trust of African-American patients than doctors who look like them. Doctors need to go into the community and understand why their patients feel helpless.

"Despite all our resources here, we won't move the needle in terms of reducing disparities unless we actually have a full understanding of the social determinants of health."

And those resources are finite, and uncertain. But Alan Freeman, Ross and Kimmey all said the region is moving in the right direction. And they all expect the overhaul of the nation's health care system signed in March to make it even easier for patients to access health care--and providers to supply it.