21st-Century Mission
D.C. Clinic for Immigrants Aims to Stay True to Its Roots in Changing World

By Pamela Constable
Washington Post Staff Writer
Tuesday, July 29, 2008

The waiting room at La Clinica del Pueblo is a busy but intimate scene where doctors greet patients with a hug, new mothers drop by to show off their infants, and Spanish-speaking seniors come for help translating their mail. No one minds if you miss an appointment or try a home remedy for your ailments.

The ethos of the nonprofit clinic in Columbia Heights, founded in 1983 to help the poorest, most marginalized refugees from Central America, is summed up in a plaque just inside the entrance: "Our mission is to provide free and culturally appropriate health care to the Latino community."

But today, La Clinica is trying to leap into the 21st century by modernizing its operations and stabilizing its finances through an annual federal grant. In return, it must meet government requirements to double its patient load, increase revenue and make services more efficient.

The changes, though recognized as necessary by most people connected with the clinic, have also led to a severe cash crunch, a bitter internal debate about whether its all-embracing mission has been betrayed, and a worry that its traditional clientele will no longer feel comfortable or welcome.

"I understand that we need to create structures and systems as we grow, but it is sensitivity to clients that makes this place so special," said Omar Reyes, an HIV/AIDS counselor. "We were created to help a population that fled from the trauma of civil wars and crossing borders. The idea was not to cause more trauma or put up more barriers. We have to modernize, but without losing the essence of what we are. This is my great fear."

La Clinica was founded by an exiled Salvadoran doctor, Juan Romagoza, who believed that health care for poor immigrants should be free. For years, it charged nothing for most services, surviving on volunteers and charity. Last year, as part of becoming a federally qualified health center, it switched to sliding-scale fees based on income, bringing strong objections from some staffers.

Romagoza, a political refugee and torture victim with fierce egalitarian ideals, quit as the clinic's director early this year, in part because he disagreed with the way it was changing, and returned to El Salvador.

To continue receiving federal grants, the clinic must go even further, charging a minimum fee of $20 and seeking more patients with Medicaid or other insurance. Now, every new patient is greeted by a staff member carrying a laptop computer to record personal information that once would not have been requested.

The changes have been especially trying for employees, who must fill out myriad new forms, keep better track of expenses and either cut back or formalize the services that are not strictly medical, such as family chat sessions and cooking classes.

A related concern is the amount of time staff members spend with patients. Many local Latinos have come to view La Clinica as a place they can drop by to share their troubles or joys, and the staff has always accommodated patients who cannot plan appointments because of irregular work demands.

One recent morning, a couple came in and asked for Sammy Caro, a case manager with a heavy workload. They had no appointment but were there to show him the newborn boy they had named after him. Caro dropped everything and devoted his full attention to the baby, who was asleep in his mother's arms.

"Sammy is really like my family," said the beaming father, Jesus Salinas, 41, a hotel cleaner from El Salvador. "He has helped me with so many things over the years. Whenever I come in, he sees me right away. I really appreciate that. We went through a lot of names for the baby, but then we decided it should be Sammy."

Soon there might be less time for such moments. To qualify for the new federal grants, the clinic must double its patient load of about 7,500 a year and increase its income from fees. According to Mauricio Silva, chairman of the board, doctors normally spend half an hour with each patient. To squeeze in more visits, he said, that may have to be cut to 15 minutes.

Government officials said they recognize the hurdles facing an informal community clinic as it upgrades to a computerized facility that tracks every penny, pill and patient. But they said the rewards, including cheaper prescriptions and free malpractice coverage, as well as the guaranteed annual income, are worth the hassles.

"The first year probably feels like a blessing and a curse," said Sharon Baskerville, an official at the District's Bureau of Primary Health Care. "The advantage is a grant that provides a level of sustainability, but it comes with obligations, and some health centers are more prepared than others. We can provide a lot of support, but they may not even know what they need."

Don Weaver, an official with the federal Health Resources and Services Administration, noted that some required changes bring clinics closer to their patients. They must provide interpreters, and half the members of their boards of directors must be clients. The goal, he said, is to "better meet the needs of the poorest, least healthy and most isolated members of society."

Although many patients and staff members say they miss Romagoza's dynamic leadership and fear that their cozy clinic will be overwhelmed by bureaucracy, others are relieved to leave behind the hardships. The service operated for years on the second floor of a nearby church annex, staffed mostly by volunteers and always low on supplies.

In 2003, it moved to the current facility on 15th Street NW, with modern equipment, bright lights and a larger paid staff. The clinic offers mental health counseling, HIV/AIDS testing and outreach, exercise classes, family planning and a children's playroom full of stuffed animals and books.

"In the old building, we had no heat or air conditioning, one dial phone and one old copy machine. Sometimes we had to carry patients up the stairs or go down to give injections," said Rosa Quintero, 61, the patient-care coordinator, who fled the civil war in El Salvador in 1979 and joined La Clinica as a volunteer in 1991.

"Here things are much better, and the new changes are important. But we also have to remember who we are here to serve," Quintero said. "The woman who comes in with a headache, worried about her children back home, with no English and no documents. I think to myself, that was me once, and I must never forget it."

In some ways, the ideological roots of La Clinica have become outdated. The Central American wars are over, and many Latinos have become legal residents with American infirmities; the most common patient complaints are diabetes and high blood pressure.

Yet staff members said many patients have the same ailments as always, such as aching backs from heavy labor or depression from family separations, as well as new anxieties that stem from children joining gangs or the recent crackdowns on illegal immigrants. Clinic officials said that they did not know what percentage of their clients are illegal immigrants but that about 60 percent are uninsured, and a majority of the adults are functionally illiterate.

"We still see a lot of Third World problems, such as parasites and people who have never been vaccinated," said Alicia Wilson, director of development. "We always think of health care in the broadest terms. We have totally changed our structural model in order to survive, but the spirit of the clinic is alive and well."

One thing that has not changed is the remarkable loyalty of La Clinica's patients, who say they would never feel comfortable anywhere else. Many are trying to help the clinic through its cash crunch, selling raffle tickets for round-trip tickets to El Salvador donated by Taca Airlines.

"I would never abandon the clinic. It is like my own house," said Leonora Gutierrez, 63, a member of the patient representative committee. She spent years cleaning offices before she injured her shoulder. "I have a few ailments, but they taught me about healthy cooking. I don't go to fast-food places anymore," she declared proudly. "If the clinic had to shut down, we would all become orphans."