The Outpatient is In
When then mayor Koch announced the closing of Harlem's Sydenham hospital back in 1980, all hell broke loose. Angry protesters stormed the hospital.
Demonstrators occupied offices for 10 days. And city officials learned an important lesson: henceforth no one would ever be so impolitic as to close a public hospital outright. The Sydenham blunder paved the way for today's more clandestine approach to hospital downsizing, in which the city reduces its contribution to the Health and Hospitals Corporation and the agency is thereby ''forced'' to make cuts to the public hospitals.
Sydenham, which did end up closing after much wrangling, left another legacy as well. When the hospital shut its doors, the federal government agreed to fund outpatient centers to serve the neighborhood's residents--a move that was seen as a sign of things to come in the city's health care. Five clinics, including the Sydenham health center, which had been associated with the hospital before it closed, then joined to create the Renaissance Health Care Network in 1988. With sites at public schools and housing projects throughout Harlem, Renaissance was hailed as a groundbreaking step toward improving the community's health, reaching people who might not have made it to the hospital, and treating them before their illnesses got worse.
Today, the city's Health and Hospitals Corporation, which runs Renaissance, has taken another big step into the world of public outpatient care. HHC still views Renaissance with pride, but the spanking-new, $45 million Ron Brown center is the corporation's latest crown jewel. Located just around the corner from Harlem Hospital on Lenox Avenue, the splashy facility offers an undeniably wide range of services, from audiology to cancer control to treatment for memory disorders. With playful frills such as fish tanks in the central areas and fun-house mirrors in pediatric waiting rooms, HHC is clearly trying to court patients who haven't already been wooed away by private health-care providers.
The Ron Brown center may prove a litmus test for how well the city agency can manage in today's competitive health-care market. HHC's task of caring for the poor and uninsured while somehow turning the kind of profit the Giuliani administration expects is a daunting one. And its prospects for success are less than rosy, as one critic sees it. ''Does it keep HHC in the game? I don't think so,'' says Howard Berliner, professor of health policy at the New School. The center, while newly constructed, has been in the works since before the Dinkins administration. In the meantime, says Berliner, the cutting edge of health care has actually evolved back to the tried and true doctor's office setup. Ambulatory care centers, which generally have an institutional feel, are becoming a thing of the past in the private sector. ''It's not clear that people will be happy with the old-style facility,'' says Berliner.
For neighborhood health activists, however, the issue seems less the center's style of care than its timing. Ron Brown's opening came just before HHC axed 252 staffers at Harlem Hospital, which provides backup care to the center. But such cutbacks, spread throughout HHC, leave advocates wary about the city's commitment to keeping the clinics adequately staffed and the hospital open.
''We agree that the system needs to be transformed,'' says Diane Lacey Winley, a Harlem-based community advocate and City Council--appointed member of HHC's board. ''We just worry that a community will be wiped out in the meantime.'' Winley bases her concerns on HHC's growing stinginess (the city has cut its contribution to an all-time low) as well as on her long history as an advocate for Renaissance. Winley, who goes to Renaissance for her own health care, says Renaissance users have had to periodically fight to maintain services at the network. Between cuts and reassignments since 1994, the network has lost more than 100 workers and Winley foresees similar struggles for the Ron Brown center.
Modibo Baker, who chairs the Renaissance community advisory board, worries that the city is moving toward a future in which it will run clinics, but not hospitals. The whole system, he fears, will ultimately be dominated by a few conglomerates. ''The clinics would just be tentacles for these giant private hospitals,'' says Baker. Baker predicts that if Harlem Hospital were to close, Presbyterian Hospital, a private hospital roughly 30 blocks north, would step in to provide inpatient care to those from Ron Brown. But because Presbyterian doesn't share HHC's legal obligation to treat all who need care, Baker worries it may underserve the uninsured.
HHC has pointed to the Ron Brown center precisely to dispel rumors that it is trying to close Harlem Hospital. The agency has no intention of closing Harlem, insists HHC spokesperson Jane Zimmerman, who goes on to argue that ''the disinformation that Harlem is being shut down has done more to damage the image of HHC than the limited staff reductions.''
Whether it bodes badly for Harlem Hospital or not, HHC's heavy investment in the Ron Brown center does at least speak to its effort to claim a place in the ultracompetitive world of today's health care. MetroPlus, the city-owned managed-care program, is trying to snag medicaid patients as they walk into the lobby. Shiny TVs suspended from the ceilings show the Muppets to children--and Jerry Springer in the adult waiting room. (HHC staff say programming will soon be taken over by educational videos.) Each floor has an area where financial counselors help patients arrange for payment and apply for medicaid (using today's health business--speak, HHC calls these ''customer-service centers''). And official greeters are on every floor to direct patients to their appointments.
The beauty of the arrangement is that, like all the care HHC provides, this quintessentially modern, consumer-oriented approach is bestowed on the insured and uninsured alike. ''We focus on all of our patients as if they're in managed care,'' says Audrey Weston, an associate executive director at HHC's North Manhattan Network.
HHC's odds in the growing competition for medicaid recipients--and their revenue--may be improved by the loyalties of such patients. Austin Iles, who's waiting at Ron Brown for a rheumatology appointment, could go elsewhere for care. He's covered by medicaid and has traveled to Presbyterian on occasion. But he says he's felt more at home in the public hospitals for years, ever since he went to a private doctor who wouldn't accept medicaid and referred him back to Harlem Hospital for help. ''I'm happier here,'' says Iles.
Like every patient at Ron Brown, Iles has been assigned a regular physician. And all the doctors at the center, many of whom live in the neighborhood, have admitting privileges to Harlem Hospital. ''Patients get to see their own doctors in both the hospitals and the clinics, so the care isn't fragmented,'' says Renaissance's chief operating officer, Gayle Lewis, who was also closely involved in launching Ron Brown.
No doubt Lewis was chosen to get the Ron Brown center off the ground because of her long history with Renaissance, which she has guided through its growth and struggles. She may have similar success with her latest project. Clearly the doctors, nurses, and patients who greet her warmly as she passes through various waiting rooms are on her side. Unfortunately, stiff competition in health care and the city's fiscal austerity are not.
This is the last of three articles on the status of public health care in the city.
Mayor Giuliani recently complained that public hospitals have become ''job centers.'' But as he--and the city's Health and Hospitals Corporation--complain of the bloat in the system, vital statistics may speak louder than empty hospital beds when it comes to the health needs of a community.
Pointing to the police department, which hasn't been asked to ''rightsize'' due to the drop in crime, public-health advocates argue that any excess in the city's health budget could be well spent on prevention. Harlem, a federally designated ''medically needy'' area, will no doubt benefit from the preventive services at the new Ron Brown center, including nutrition, family planning, and sickle-cell treatment. But, as the following look at some of the community's vital signs shows, Harlemites still have a long way to go for health equity.Infant mortality: The number of babies who live through birth is seen as one of the best gauges of a community's overall health. Central Harlem has had the highest infant-mortality rate in the city since the health department began keeping statistics in 1950. While most infant deaths are thought to be avoidable with appropriate prenatal care, more than 15 of every 1000 infants die, making Harlem's infant mortality rate almost twice that of the city as a whole.
Cancer: The death rate from cancer in Central Harlem is also the highest in the city. Cancer, much of which is associated with diet, smoking, and toxins in the environment, causes almost 300 of every 100,000 deaths in the community, compared to less than 200 citywide and 129 across the country. HIV/AIDS: AIDS is now the number one cause of death for both men and women between 25 and 44 in Harlem. With more than 179 of every 100,000 people dying of AIDS in Central Harlem in 1996 (the most recent year for which statistics are available), the neighborhood's AIDS mortality rate is almost 15 times the national average and more than two and a half times the city average.
Overall life expectancy: Considering the collective effects of Harlem's many epidemics, researchers in 1990 figured that a man in Bangladesh had a better chance of making it to 65 than his counterpart in Harlem. A more recent study came to the grim conclusion that a 15-year-old boy in Harlem has a 37 per cent chance of living until age 65. For girls, the chance is 65 per cent.