On a normal day, 36-year-old Rugiatu Kabia would spend the morning and afternoon caring for her three elementary-school-age children before heading to her part-time job on the night shift at a nursing home in Montgomery County, Md. But on Monday, March 16, she had extra responsibilities. In the morning, she needed to complete a rigorous coronavirus prevention training course — her nursing facility was already practically on lockdown, with temperatures taken when staffers arrived to work. Then she had a doctor’s appointment of her own, to check on her blood pressure, which in the past had been so dangerously high that she’d had to stop working full time. If anything, the stress of the coronavirus outbreak was making the problem worse. “It’s too much anxiety, honestly,” Kabia told me. “You think, God, who is going to get infected with this?”
Cases of covid-19, the disease caused by the novel coronavirus, are threatening to overwhelm the American medical system, but all the other diseases and ailments known to humankind don’t stop just because there’s a pandemic on. What will become of the people, like Kabia, who are suffering from everything else?
That is the quandary facing Kathleen Luton, who was waiting for Kabia in an examination room in a squat county office building in Silver Spring. Luton is clinical director of Mobile Medical Care, known as MobileMed — a chain of three brick-and-mortar clinics and three RV-style mobile doctor offices that park at designated community centers or churches. The six sites are strategically located near less affluent population centers — though the medical RVs have recently had to close and send their patients longer distances to the clinics, because a prohibition on large gatherings has shuttered the churches and centers that provided parking and bathrooms.
Luton washed her hands in the examination room as Kabia checked in at the front desk. Even before they arrive, patients are screened over the phone for symptoms of covid-19: Fever? Cough? Travel to hot spots?
I stepped outside the room while Luton examined her patient. Coronavirus warning posters in Chinese and Spanish — just a sample of the languages spoken by patients served by MobileMed — hung on the clinic’s walls. Earlier, I had met a MobileMed nurse practitioner whose patients find comfort in being able to describe their symptoms to her in Amharic. Luton can get by speaking French to patients from West Africa and the Caribbean. When necessary, a translation service on speakerphone rounds out the polyglot medical chatter.
Since it was founded 50 years ago, MobileMed has prided itself on keeping its working poor and uninsured patients from resorting to emergency rooms for primary care. Even after the Affordable Care Act expanded access to health care, almost 5,000 patients a year in one of the nation’s wealthiest counties still must turn to MobileMed for services from wellness visits to managing diabetes and hypertension. They pay $40 per visit — if they can. County and federal support, plus private donations, make up the bulk of MobileMed’s budget. The money stretches further because MobileMed relies heavily on volunteers. Many are retired from long medical careers — older folks, in other words, who are precisely the cohort considered most at risk of illness from the coronavirus.
Community clinics come in many varieties — MobileMed is just one model — but what they share is an overall mission and philosophy. They were never designed to take on threats like covid-19, but by carrying on with regular medical treatment under increasingly difficult and dangerous circumstances, they buffer the already buckling emergency medical system from a wave of non-coronavirus patients.
“You can imagine if we were not here,” says Conrad May, a retired internal medicine and geriatrics specialist who volunteers for MobileMed. “The people who needed some medical attention would have no recourse except to go to emergency rooms, and so that would make things even worse.” At 63, he is old enough to be considered vulnerable to serious illness from the virus. He and his wife are also taking care of her 91-year-old aunt at home, and May must not infect them. He told me he weighed the chances of infection, began taking extra precautions — and resolved to keep volunteering at the clinic. “I think the risks are worth the benefits,” he says.
In line with guidance from the Centers for Disease Control and Prevention, MobileMed is telling patients who call in with a fever to stay home. Only those having trouble breathing should call 911 or go to the emergency room. Those with ambiguous symptoms — cough and fever — are put on the phone with Luton, who can try to distinguish between allergies or flu and something more serious. Some patients, feeling scared and desperate, are begging for a coronavirus test — which MobileMed, like most providers at this point, does not have.
Later that afternoon, Luton received a grim message from a nearby hospital: Referrals for nonessential imaging studies — ultrasounds, MRIs and the like, crucial components of routine care for some patients’ chronic diseases — would no longer be accepted. To Luton, it was another bleak sign of a shaken national health-care system. “Everybody is hunkering down,” she said. “What’s going to happen is, the country is going to be taking care of covid and emergencies. And that’s it.” Places like MobileMed will be left to care for the rest.
Even before the coronavirus pandemic made home the safest place to be, Sachin Nagrani, a 40-year-old specialist in family medicine, has been telling patients to stay home — that the doctor will see you there. His office isn’t much to visit anyway: It’s basically a medical storeroom in a shared workspace near Dupont Circle. Early on a Wednesday in mid-March, I found Nagrani and Harsha Rao, 25, a medical assistant, checking the inventory packed into a silver rolling bag — sutures, syringes, stethoscopes, a scale — while monitoring doctor-visit requests flowing in through a smartphone app.
Heal, the national health-care company Nagrani and Rao work for, was founded five years ago to bring back the personal touch of the old-fashioned house call. The idea was to give patients the option of being treated in the comfort of their homes while avoiding potential infection in a public health facility. An app made booking appointments easy and provided access to records of care.
Some patients turn to Heal because of the convenience. Others like the price — $159 per home visit, which is covered by major insurance plans, but, for some who may lack insurance, can also be more affordable than a regular doctor visit. Nagrani, the company’s medical director, joined three years ago when Heal expanded into the District and Northern Virginia. “I was really looking for a practice setting where I could spend some more time with patients and actually perform what I had been trained to do to address their issues,” he told me.
Now the pandemic is forcing another leap forward. Self-isolated in their homes, some patients don’t want even a doctor wearing sanitary booties and, when necessary, a mask and gloves to breach the perimeter of their sanctums. To adapt to the new conditions without interrupting most types of care, Heal is emphasizing telemedicine — video encounters between patients at home and Nagrani on his tablet. Televisits cost $79, usually covered by insurance.
In preparation for his virtual patients, Nagrani put on his classic white doctor’s jacket, stitched with his name, over his sweater and draped a black stethoscope over his shoulders. Even though the stethoscope was never going to snake through the cellular signals and listen to anybody’s chest, it was a key detail in a uniform meant to communicate calm and confidence. “That’s the image people expect,” he said later.
The virtual sessions have come in two varieties, Nagrani explained: patients with routine needs, such as medicine refills; and patients with upper-respiratory symptoms in either themselves or their children who want to know whether they are infected with the coronavirus. Nagrani generally offers advice similar to Luton’s at MobileMed. “The vast majority of people are actually going to have mild symptoms, and those mild symptoms are going to pass,” he says. “The goal then becomes to make sure that it’s contained. ... What we’re talking about with patients who do have mild symptoms is how to self-isolate and to care for that person without everyone in the household getting sick.”
Yet even amid the pandemic some patients desire the old-school home visit that Heal reinvigorated, and for others it is actually medically preferable. “The big challenges have been for patients that are unable to be managed via telemedicine, but they have chronic conditions,” says Nagrani. He describes a “sort of balancing act” between the risks of “outside people coming into the home” and the benefits of being able to provide in-person care.
And so, after his telemedicine visits, Nagrani set out to make five house calls. These were patients who did not report signs of covid-19 and who, for one reason or another, needed to be treated in the home. They included a man with nausea, diarrhea and overall weakness who said he had felt too weak to drive to his regular doctor’s office; a woman who had suffered a stroke and could not be easily moved; and a woman with a spinal cord injury who uses a wheelchair and who was due for a checkup.
Rao, the medical assistant, zipped up the silver rolling bag and wheeled it to the garage of their workspace building. The son of a surgeon in India, Rao immigrated several years ago and had been scheduled to take his oath of American citizenship the day before in Baltimore. The ceremony was canceled because of the outbreak. He’s starting medical school in the fall. The pandemic is showing him “the responsibility that we are taking” by becoming doctors, he told me.
Rao and Nagrani climbed into a blue Chevy Cruze and, with Rao at the wheel, set out for the Virginia suburbs. Rao parked in a cul-de-sac in McLean before a big brick house with a horseshoe-shaped driveway. We paused on the front stoop to pull booties over our shoes before entering. The patient who had reported nausea was sitting up in bed in the master bedroom, shirtless, wearing a surgical mask, with a comforter pulled up to his waist. He recounted his symptoms to Nagrani and added, “I checked my temperature. It’s actually below normal.”
Nagrani took the patient’s pulse and blood pressure, probed for abdominal pain and had him get out of bed and step on a portable scale. Rao wiped each implement with sanitizer before stowing it back in the rolling doctor’s bag. Diagnosis: a virus, but not that virus — a stomach bug that should disappear soon. Nagrani prescribed a mild diet and medicine for the nausea.
The coronavirus outbreak had already upended the patient’s life, though. (He asked that I not identify him to protect his medical information.) He’d had to temporarily close his business, and now his family was sequestered in the house. It reminded him of his native Kazakhstan, he said, in the days of the Soviet Union, when the doctors made house calls and there was little on store shelves. “Seeing people being given only two canisters of wipes, antibacterial wipes, only two per person, that really rang the bell,” he told me. “Because I remember when two bricks of butter were [rationed] to each family. ... I think we’re resilient. We were joking: We survived the Soviet Union. We can survive anything.”
The house calls proved to be revealing glimpses into how patients are coping, even when the coronavirus has not struck them — and how doctors must confront covid-19 even when they are not treating it. In each of the three visits I sat in on that day, Nagrani offered coronavirus counseling, letting patients know that videoconferencing was always an option if in-person visits couldn’t be arranged.
Nagrani was also moving up long-scheduled house calls — like 75-year-old Elyse Savage’s annual checkup — in case the pandemic’s spread precludes them in the coming weeks. “We were watching the news, and it’s overwhelming,” Savage said as she welcomed Nagrani to her third-floor condominium in Alexandria. “I’ve been washing my hands so much my knuckles hurt.” Savage, an artist who used to own a gallery and frame shop in Georgetown, suffered a spinal cord injury after a freak fall in her house six years ago. Now she maneuvers with a wheelchair or a walker.
During the 45-minute checkup in Savage’s living room, decorated with paintings and prints, the pandemic kept edging into their conversation. Savage said one of her sons and his wife had to temporarily close the gym they recently opened. And she is distressed that she can’t have physical contact with her young grandchildren. “It’s just like torture,” she said. But “I thought, you know, as painful as it is, I’m going to be smart.”
She won’t let the situation crush her spirit, though. Serving in the Peace Corps decades ago in St. Lucia taught her to be resilient. “Saturday I rolled myself out to the pond” nearby, she said. “I brought my wipes and I wiped off the things that my hands would touch. Did some exercising. I could stand up and do some squats and stuff like that. And it just felt so good.” She has taught herself to use her foot to press the elevator button in her building.
Nagrani nodded approvingly. Satisfied that his patient was in good shape, the doctor rose to go. “Well, I’ll be in touch,” he said. “It will probably be remote the next time we talk.”
Three days after I visited MobileMed’s clinic in Silver Spring, I stopped by the Rockville clinic, which is located in a county health services building. Signs on the main door asked in various languages: “Should You Come In?” (If you had a fever or cough, the answer was definitely no.)
Inside, more signs, created by Kathleen Luton the night before, hung on the door to MobileMed’s wing: a red stop sign and an advisory that this was no place to come for a coronavirus test. If you had a cough, you were to put on a mask before opening the door. If you needed a mask, you were to call a number and someone would bring you a mask. In the waiting area, Elvia Mejia, a patient in her mid-70s, started coughing. She just had asthma, she told the alarmed receptionist. “It’s not fun; everyone suspects you,” Mejia said. “I have to tell everybody.”
The “hunkering down” that Luton had foreseen for the national health-care system just a few days before was already beginning to affect MobileMed. There were still plenty of patients arriving in search of care, yet two-thirds of the clinics’ 50 volunteers — including some doctors — as well as some paid staff members were making the hard choice to stay home themselves because their age, family circumstances or other medical conditions put them at greater risk. MobileMed’s executive director, Peter Lowet, had told me earlier that he was planning for the possibility that many of the staff could have to self-isolate if they develop symptoms or have contact with someone who tests positive for the virus — which will make providing care to the community only more challenging.
Part of the solution will be — just as at Heal — telemedicine. MobileMed was scrambling to make such visits available in the coming days. “We’re hoping to still be here,” Lowet says. “But you know, I think it will just be a skeletal — something’s going to give in the next few weeks.”
As the patients came and went, I saw how important the physical presence of the volunteer doctors in the clinic can be. I met a 75-year-old president of an arts nonprofit with diabetes who had just seen Conrad May, the volunteer internal medicine and geriatrics specialist. The artist told me his blood sugar level was off the charts. Earlier that day, a woman with an infected uterus had been treated by Paul Burka, a retired gynecologist volunteering for MobileMed. At 74, he said he would keep seeing patients until the end of the month at least, because “there’s a need.”
I found Luton in the examination room where she treats patients at this clinic. She was planning to order equipment to custom-fit specialized filter masks on clinic staff. But she knew she wouldn’t have enough sizes of masks to snugly fit all faces. She is 63 and has her own family to think of, too: Her 85-year-old mother is staying with her for now, on the theory that Howard County is safer during the pandemic than northern New Jersey.
“We’re going to do as much as you can through telehealth,” she told me. “And there’ll be the last people standing [in the clinic] — maybe me, maybe a handful of other people. We’ll consolidate. ... We’ll figure it out probably on the fly, as everybody else is doing. We’re not going to be unique in that for sure. But I’m gonna be honest with you. I can’t say that it’s scary for me, but I’m very concerned. You know, I’m not young anymore. And I want to be healthy and continue to live my life. I’m not trying to be a martyr here. But intelligent, capable people need to be here to continue the work that needs to be done.”
David Montgomery is a staff writer for the magazine.
Photo editing by Dudley M. Brooks. Design by Christian Font.