Clinics struggle to keep up with needs of rural, poor communities

Grace Beahm
The Post and Courier

Dr. Edward Rojugbokan of Cross Family Health Center counsels patient Victoria Mack on options to help the pain in her hands.

They wait patiently. For hours. Sometimes all day.

But they don't complain. The tiny clinic in Cross has become part of the landscape here, like an ancient oak or river estuary, a place upon which residents can rely, a place that was built a quarter-century ago just for them.

The waiting room is always full of people, and more — perhaps a half-dozen — sit on benches and chairs in the short hallway beyond the door. These are some of the residents of rural South Carolina, mostly black, mostly middle age or elderly, suffering from ailments acute and chronic. One man comes because of an ingrown toenail; a woman with a sprained knee enters on crutches; many others come so the doctor can help them control diabetes or heart conditions. Occasionally, someone requires emergency care because of an accident.

The clinic has no expensive equipment, no EKG or X-ray machine, no blood lab, no CAT scan or MRI machine, no medical specialists, no ambulance service. It has no pharmacy. The nearest one is 25 miles away in Moncks Corner.

What it does have: two exam rooms, a room devoted to col-lecting blood samples, a small office area, a compact medicine closet and a room that sometimes accommodates staff on their lunch break and sometimes serves as a place for patient counseling.

The distance between the front and back doors is about 15 paces.

Dr. Edward Rojugbokan has seen it all. He calls his patients by their first names. He is a central figure in the community. He is beloved.

He is the only doctor around for miles.

Adding it up

The Cross Family Health Center is part of the Franklin C. Fetter Family Health Center network of six medical bureaus, overseen by Ronald Ravenell. The Fetter network, in turn, is one of 19 community health care providers in the state.

Ravenell, who has helped run this and other so-called 'safety net' clinics for 35 years and who took the helm of the Fetter network in 2004. He said the goal of the community health center is to help the underserved overcome economic and geographic barriers, making access to health care a little easier. Communities can flourish culturally and economically only when the people are healthy and active, he says.

Compared with other states, South Carolina is not very healthy. It ranks in the bottom tier consistently across several indicators and currently ranks 46th in health outcomes overall, according to federal government statistics. At 9.3 percent (rate per 1,000 live births), the state's 2004 infant mortality rate is one of the worst in the country, 2.34 percent above the national average. Its rate of obesity and diabetes is high and on the rise.

For blacks, the statistics are especially grim. The U.S. Department of Health and Human Services' Office of Minority Health reported recently that infant mortality rates reached 13.6 percent in 2004 (the last year for which data is available), and that blacks were significantly more likely than non-Hispanic whites to develop new cases of certain cancers, to have lower cancer survival rates, to develop diabetes, hypertension and heart disease, HIV/AIDS and to have a stroke.

The total number of HIV patients in South Carolina seen by these safety-net providers, has nearly doubled from about 5,900 in 2002 to 10,300 in 2005, according to the S.C. Primary Health Care Association.

Health officials say these disparities constitute a troubling trend at a time when access to health care and affordable prescription drugs is increasingly limited for many Americans who cannot afford premium insurance policies. Increasingly, the health care debate is framed as a moral issue as many, including most recently filmmaker Michael Moore in his new movie 'Sicko,' call for some form of universal health care underwritten by government, not corporations.

Nearly 20 percent of South Carolinians are uninsured at any given point during the year (the national average is 15.2 percent), and more than 40 percent have no private insurance. But the state's relatively high unemployment rate — at 6.5 percent, it's nearly 2 percent higher than the national average — apparently is not the culprit. The majority of the state's uninsured have jobs, but because they are self-employed or work for small businesses, the rising cost of health care coverage is prohibitive, the Primary Health Care Association reports.

The Fetter network of clinics caters to anyone in need of care, but only 54 percent of Fetter's patients have some sort of insurance, down 10 percent since 2003, and 14 percent have private insurance such as Aetna or BlueCross BlueShield. The rest rely on the center's sliding-fee scale, which requires payment from every patient but determines the size of the bill according to an individual's ability to pay.

In the beginning

Elijah Wright's grocery on S.C. Highway 6, a stone's throw from Lake Moultrie's west shore, is Cross' unofficial town hall. It's the place where residents meet to buy cold cuts, detergent and other essentials, and to touch base with the 75-year-old Wright, who has lived there all his life. He is the people's advocate.

Somehow, Wright manages to get things done. In the early 1980s, he decided the community needed a health clinic. A neighbor donated a building just up the road, and Wright persuaded the electric and telephone utilities to donate their services. He invited Dr. Thaddeus Bell to become the local physician.

'We need everything!' Wright said. 'There's nothing here within 20 miles. That was the primary purpose of the clinic to begin with. We're so far away from everything.'

In the beginning, the clinic was free, open only in the evenings three or four days a week. Bell and a couple of nurses volunteered their time.

Before long, Wright and Bell wrote a grant to secure funding from the Orangeburg Family Health Center. Area pharmacies provided free medicine.

'It was an instant success,' Bell said.

Once a budget was established, Bell was able to get paid. He stayed at the clinic for seven years even as he worked by day as an attending physician at the Veterans Affairs hospital in Charleston.

'I went through several cars driving up there (to Cross),' he said.

In his spare time — what little of it there was — Bell worked in the emergency room at Trident Medical Center. As a result, he gained hospital privileges, the only black doctor to do so at the time, which meant he could get patients he saw at the Cross clinic admitted at Trident. This came in handy when he was confronted by serious illness or injury, he said.

Closing the gap

Bell's medical career has been a roller-coaster ride that has taken him from a rural Beaufort County and Ridgeland clinic to the Medical University in Charleston, where he became associate dean of diversity at the College of Medicine. In between, he worked at the VA hospital, Cross clinic, Trident hospital, Berkeley County jail, where he was medical director, and the Air Force, where he served as a flight surgeon. He started a private practice and eventually ran the office of diversity at the Medical University. His experiences have, perhaps inadvertently, gained him an intimate familiarity with health disparities and their causes.

That knowledge, the fruit of his experience as both an institutional physician and a lone ranger, has transformed him into a sort of activist doctor. He addresses the black community directly on the radio and lecture circuit and in newsletters. He pushes lawmakers and community leaders to challenge the status quo. He publicly bemoans recent trends that have threatened the health of minorities and encouraged complacency among those most at risk.

His emphasis, then, has become education. Though Bell said that disturbing social issues contribute to health disparities, including institutional racism and corporate exploitation, he also argued that ignorance and laziness are partly to blame.

'African-Americans and other minorities contribute somewhat to their own problems,' he said. They wait too long to seek care, succumb to high-fat diets, rely on misinformation and old wive's tales, fail to exercise and don't always follow the instructions of their doctors.

Economics is certainly a big problem, Bell said, adding that many among the poor must choose between medicine and putting food on the table should be cause for alarm. But blacks are failing to take measures to prevent serious health conditions in the first place, he said.

'African-Americans have higher instances of colon, prostate and breast cancer not because of race, but because of their failure to get tested (early),' he said.

In an attempt to address the problem, Bell has launched an initiative called Closing the Gap in Health Care. It has two goals: to encourage more young blacks to become doctors (and to train at the Medical University of South Carolina), and to educate members of the community about preventive health care.

The initiative has gained support from key allies, including U.S. Rep. James Clyburn, D-S.C., and Terry Seabrook, the owner of the real estate firm The Space Co.

Last month, it established the Thaddeus John Bell Scholarship Endowment in cooperation with Select Health, an insurance provider. The endowment is meant to provide financial assistance to minority medical students who attend any of the Medical University's colleges and already has raised $100,000, according to Motley Rice lawyer Marlon Kimpson, chairman of the program's steering committee.

The extra effort

Since the health care industry — private practitioners, hospitals, insurance and drug companies, government agencies — can't ensure that all Americans have sufficient access to medical services, the nonprofit sector and certain individuals, such as Bell, strive to bridge the gap.

Last December, The Palmetto Project, a Mount Pleasant-based nonprofit initiative, launched its Healthcare Information & Referral Network that eventually will provide online and toll-free telephone assistance to those in the state without private health insurance, according to Executive Director Steve Skardon. The program, funded with a grant from the state Department of Health and Human Services, uses a health data warehouse to link those in need with affordable medical care, free and discounted prescriptions, and local prevention and community-based health education programs.

It is among the latest efforts of the past 40 years to reach the underserved population, Skardon said. During the 1970s and 1980s, then-U.S. Sen. Fritz Hollings promoted the establishment of community health clinics, putting South Carolina ahead of many other states, Skardon said.

'By the time everyone else discovered this, we were well on our way,' he said. 'If you have no health insurance, South Carolina is really the best place to be because we have more resources than other states.'

Another resource is soon to open.

The Barrier Islands Free Clinic is just that: free. Its executive director, Dr. Carolyn Wong Simpkins, said the clinic, on Johns Island across from St. John's High School, is expected to open its doors by the fall.

The clinic is based on a model, called Volunteers in Medicine, first introduced on Hilton Head Island in the early 1990s by Dr. Jack McConnell. Retired doctors, nurses, dentists and other providers are put to work, unpaid, under the supervision of one licensed practitioner. The volunteers obtain a special medical license from the state and malpractice liability is limited by the state's Good Samaritan law.

In this manner, Simpkins said, everyone benefits. Patients receive free care and doctors find a new opportunity to practice medicine and to contribute to their community.

Simpkins said a growing number of people are slipping through a widening economic crack: They earn too much to qualify for government assistance programs such as Medicaid but cannot afford private insurance. Some work hard at several part-time jobs, but employers don't provide health benefits. These patients are becoming a burden on public hospitals (funded in part by taxpayers), which must treat injuries and acute medical conditions by law, and on community clinics that require payment but collect less and less, Simpkins said.

A free clinic, therefore, can relieve some of that burden, she said.

But, she warns, it is not a solution to the access problem. The model works only in certain areas, such as Johns Island or Hilton Head, where rich and poor live in close proximity. And the Barrier Islands Free Clinic won't treat more than once a patient who has some form of coverage, or could qualify for it, she said.

A growing need

Coping with the logistics of providing health care to increasingly disenfranchised populations is challenging enough when the legacy of institutional racism is factored out, Skardon said. But that legacy can't be ignored.

The history of racial prejudice and abuse within the health care industry, endured by blacks during the segregation era and epitomized for many by the infamous Tuskegee Syphilis Experiment, has fueled a feeling of distrust, Skardon said.

From 1932-72, the U.S. Public Health Service conducted an experiment on 399 poor black sharecroppers from Alabama. The men, all suffering from late-stage syphilis, were never told what disease they had, only that they were being treated for 'bad blood,' according to James H. Jones, who wrote a book about the government's project called 'Bad Blood: The Tuskegee Syphilis Experiment.'

Government doctors never treated their illness. Data was to be collected from autopsies. The symptoms of tertiary syphilis include tumors, heart disease, paralysis, blindness, insanity and death. By the end of the experiment, syphilis had killed 28 of the men, 100 were dead of related complications, 40 wives had been infected and 19 children had been born with congenital syphilis.

Today, many blacks still are suspicious of health care professionals and believe they are treated differently because of their race, Skardon said, an observation confirmed by patients at the Cross clinic. A big reason for this, Skardon said, is the inevitable question medical providers ask, often as soon as they set eyes on their patients: 'How are you going to pay?' Thus, perceptions of unequal treatment are perpetuated.

'There certainly is enough history in South Carolina to substantiate that fear,' Skardon said.

Unfettered care

Ravenell has spent all but three of his 35 years in the health care industry working in the Fetter Family Health Center network. In 2004, he took the helm of the organization, which seeks to locate clinics in areas that have few primary-care providers, where there is plenty of demand but not enough supply, Ravenell said.

Fetter, who was dean of the family medicine program at the Medical University, started his family health center in 1968 with a federal demonstration grant and chartered the organization in 1975.

Today, there are at least 14 full-time medical providers and a staff of about 100, Ravenell said. About 35 percent of its funding — $2.5 million — comes from the federal government. But annual budgets are enlarging even as government funding remains constant, and making up the shortfall is a challenge, Ravenell said.

A full 46 percent of Fetter's patients are uninsured, and resources are not substantial enough to serve all of them, he said. Doctors each see about 25 people a day.

The Fetter clinics strive to provide one-stop shopping for those seeking medical care, who tend to be among the sickest in the community, suffering from multiple health problems, Ravenell said. Mental health experts work side by side with physicians and dentists. Two facilities include a pharmacy that dispenses discounted drugs, filling 350 prescriptions a day, more than 88,000 a year.

'We try to be very comprehensive so our patients don't have to go all over the place for services,' he said.

Ravenell and his colleagues are working on a new initiative called the 'Planned Care Model,' which is designed to treat patients in groups assigned to specific doctors. The idea, Ravenell said, is to 'maximize efficiency,' encourage cooperation and support among patients and provide doctors an opportunity to get to know their patients better and be more proactive in addressing health concerns.

Cross' medical hub

For Rojugbokan, the daily challenge of providing quality medical care to his patients in Cross is unending, but he says he tries to stay positive, to focus on the work at hand and to help a community he has grown to love.

'We've developed a small cult following,' he joked recently during a short lunch break.

The truth is that the people of Cross and other neighboring communities have developed a deep respect and affection for their doctor. They come here from St. George, Holly Hill, Eutawville, Kingstree, Bonneau, Jamestown, St. Stephen and Pineville, not only because the clinic is affordable. They come to see Rojugbokan.

Helen Ravenell (no relation to Ronald Ravenell), 56, retired from BellSouth with full benefits. A resident of Cross, she could go anywhere but she prefers to be seen by Rojugbokan.

'I'd wait all day if I had to,' she said. On the day of her visit, she was at the clinic for about four hours. The biggest problem with the Cross clinic, she said, is that it's too small, out of date and poorly equipped. Several others in the waiting room agreed.

'You've got to go somewhere else for a lot of stuff,' she said.

Linda Butler, 53, said she had to get X-rays in Moncks Corner last year, but then her car broke down. A lack of transportation is often a problem for Rojugbokan's patients, she said. Others sometimes will offer to give someone a lift when travel is required.

Jimmy Richardson, 57, suffers from diabetes and drives 45 minutes to Cross from Cainhoy. Richardson said he worries about the overworked doctor and his small staff who must provide services in the underequipped facility. Certainly, the volume of paying patients is large enough to warrant more resources, he said. 'They really need a pharmacy here.'

If Cross ever gets a new building for its clinic, it might include a pharmacy, Rojugbokan said. Plans are in the works to build a larger facility on a nearby lot. The land and some funding has been secured, according to grocery store owner Wright, who sits on the board of the Fetter network. It's possible that one day soon patients here won't have to drive to Moncks Corner to fill their prescriptions.

Tracy Freeman, a nurse who has worked at the clinic for eight years, said the staff mostly performs 'reactive medicine,' treating already-developed problems, but that they try to educate patients at each visit.

The communication barrier can be thick, especially with older people, Freeman said.

'Some don't want to understand,' she said. They adhere to a certain fatalism and don't try to change self-destructive behavior.

But those are the exceptions, she said. 'Most try.'

Rojugbokan said he worries a lot about stroke. The Deep South is part of the 'stroke belt' because of certain chronic ailments and lifestyle choices, he said. Southerners too often eat high-fat diets, fail to exercise and forget to treat conditions such as diabetes, high blood pressure and high cholesterol levels, Rojugbokan said. The result is the highest per-capita stroke rate in the country, he said.

Part of the cause is the nature of rural life. Infrastructure is lacking in the countryside, he said. There are no gyms, tennis courts or bike trails. To get from one place to another, people drive their cars. Old eating habits persist. Bad health comes with the territory, he said.

The health care industry could do more, he said. It could be more proactive. It could strive to treat problems before they become acute. When patients seek medical attention for a severe condition, the cost is almost always higher and physical consequences longer-lasting, Rojugbokan said.

Outreach is possible, but only with more resources, he said. And it strikes him as odd that, despite significant financial incentives, systemwide change is not pursued. Consider this: The cost of treating high blood pressure is about $20 a month, Rojugbokan said. The cost of hospitalization after a heart attack or stroke is about $120,000.

A particularly troubling trend is the emergence of a cycle of failed medical care, he said. Sick, uninsured patients with conditions that cannot be adequately treated in community clinics are referred to hospitals, which, in turn, reject them if their symptoms are not critical, Rojugbokan said. The sick then return to the safety-net clinics where doctors must improvise despite a lack of resources and equipment. The financial burden on the system — and the taxpayer — far exceeds what it would cost had doctors been able to practice preventive care and to use a cohesive referral system, he said.

'As a doctor, I say everyone deserves access to good health care,' Rojugbokan said. 'There is so much need.'

The cost of drugs

U.S. pharmaceutical companies often sell their brand-name drugs abroad at a lower price than what they charge customers in this country. For example, a 2004 congressional study found that a 90-day supply of the cholesterol-lowering drug Lipitor costs about $320 in the United States, and about $180 in Canada.

'On average, brand-name drug prices charged by manufacturers, wholesalers and retailers were higher in the United States by about 70 percent,' the study concluded.

While generic drugs often cost foreign governments and health systems more, the price of branded prescription drugs is typically set based on centralized bulk buying practices and the ability of foreign governments, such as Canada's, to negotiate.

In the United States, instead, it is illegal for health professionals to negotiate drug prices with pharmaceutical companies under Medicare. In arguing for this provision, the drug lobby has claimed that higher prices are necessary to help fund research and development and other operating costs.

The result, health care providers say, is a system that overburdens those least able to pay for expensive drugs, forcing many to choose between health care and other priorities.

By the numbers

45 million: Number of uninsured Americans.

8.5 million: Number of uninsured children.

43 percent: Portion of S.C. population without private insurance.

20 percent: Portion of S.C. population uninsured at any given point in the year.

60 percent: Portion of those uninsured who are employed.

14 percent: Portion of S.C. population living below federal poverty line.

26 percent: Portion of blacks in state living in poverty.

30 percent: Portion of S.C. population that's black.

5 percent: Portion of state's doctors who are black.

$18 billion: Amount wasted in U.S. each year on avoidable ER visits.

40 million: Number of children in U.S. who don't get preventive medical or dental care.

20 million: Number of people in U.S. living in 900 high-poverty counties with no health center.

46 percent: Increase in patients treated at U.S. community health centers between 1999 and 2004.

43 percent: Portion of U.S. health center patients who are uninsured.

Sources: S.C. Primary Health Care Association, Palmetto Project, Bridging the Gap in Health Care, National Association of Community Health Centers

S.C. disparities

Racial and ethnic minority infants in South Carolina are more than twice as likely to die before their first birthday than white babies.

In the year 2000, blacks were more than nine times more likely to be reported as having HIV/AIDS than were whites.

Although the incidence of female breast cancer in the state is higher for whites, minority women, in particular black women, are nearly twice as likely to die of the disease.

Hispanic women have the highest incidence of cervical cancer, although black women are more likely to die of the disease, according to the National Cancer Institute.

Racial and ethnic minorities are more likely to develop, experience complications and die of diabetes than are white people, according to the American Diabetes Association.

Source: S.C. Department of Health and Environmental Control

On the Web

National Association of Community Health Centers: www.nachc.org

South Carolina Primary Health Care Association: www.scphca.org

Palmetto Project: www.palmettoproject.org

Closing the Gap in Health Care: www.closingthegapinhealthcare.com

S.C. Department of Health and Environmental Control: www.scdhec.net/health

U.S. Department of Health & Human Services, Office of Minority Health: www.omhrc.gov

Area community health centers

Franklin C. Fetter Family Health Center Inc.:

Franklin C. Fetter Family Health Center, 51 Nassau St., Charleston, 722-4112.

Cross Family Health Center, Highway 6, Cross, 753-2334.

Enterprise Health Center, 2047 Comstock Ave., North Charleston, 308-2400.

Lowcountry Pediatrics/Adults Health Center, 3973 Rivers Ave., North Charleston, 747-8893, 747-8755.

Moncks Corner Pediatric Health Center, 730 Stoney Landing Road, Suite 200, Moncks Corner, 761-2000.

Summerville Health Center, 700-B N. Pine St., Summerville, 821-3444.

Sea Island Comprehensive Health Care:

3627 Maybank Highway, Johns Island, 559-9901.

6326 Hollywood Drive, Hollywood, 559-9901.

600 Padgette Loop, Walterboro, 559-9901.

Reach Adam Parker at 937-5902 or aparker@postandcourier.com.