Ivan Iniguez , B.S. (1), Maria G. Contreras B.S. (2), Edgar Castellanos B.S. (2), Manuel Tapia M.D. (1), Felix Kury, M.S. (2)
1- UCSF School of Medicine
2- San Francisco State University
For the past decade the Clínica Martín-Baró (CMB) collective has hosted a free clinic out of a converted office space in a local church in the heart of San Francisco’s Mission District. CMB is a grassroots clinic founded in 2007 and established through the efforts of students and educators with the mission of facilitating access to healthcare for the area’s most vulnerable and marginalized residents. The constant advocacy for health justice has been critical in the increasingly gentrified Mission cultural district. The volunteers are San Francisco State University (SFSU) undergraduate students and University of California, San Francisco (UCSF) medical students and faculty. Through coursework and training volunteers learn to provide person-centered, culturally humble care with a deep appreciation of structural and social determinants of health that plague the community. CMB was thus created to address the lack of institutional support in addressing the health needs of the city’s most vulnerable communities, specifically the neighborhood’s uninsured, low-income, monolingual Spanish-Speaking and undocumented community.
Despite focused policy goals on expanding access to health coverage, there is still a significant portion of the population that is uninsured. In San Francisco alone, 96.5% of San Franciscans in 2018 reported having health insurance coverage; however, despite this success there was still a considerable 3.6% of the population (31,480 people) that remained uninsured within the city [1] [2]. To better understand this issue the San Francisco Health Improvement Partnership (SFHIP) report on assessing community health needs revealed that 8% of San Franciscans do not have a usual place to go for medical care and that 24% of adults have not had a routine check-up in the past year [2]. Interestingly, when also looking at preventable hospitalizations for hypertension and diabetes, complications increased by 45% and 50% respectively between 2011 and 2016, indicating that as the city continues to grow and change these conditions are not being well managed at the population level [2]. It is well established that free clinics like Clínica Martín-Baró do much more than offer free primary care services and connect uninsured individuals to care, they also prevent hospitalizations due to preventable chronic health conditions [5]. The clinic has served as a ‘safety-net of the safety-net’ specifically pertinent to the, oft overlooked, undocumented community.
In March of 2020, San Francisco city officials issued the nation’s first shelter in place order in response to the impending COVID-19 pandemic. Since the shutdown ordinance, only organizations deemed essential were allowed to operate and many community health organizations, including Clínica Martín-Baró, were forced to close. This was demoralizing to the collective as so much of the spirit of the CMB services was the in-person environment that welcomed those with few connections to the area. Additionally, the socioeconomic consequences of the COVID-19 pandemic disproportionately impacted the Latinx community in San Francisco. Unidos En Salud, a unique collaboration between Mission District community organizations in the Latino Task Force for COVID-19 (LTF), UCSF researchers, and the San Francisco Department of Public Health (SFDPH) found that although only 1.4% of Mission District residents tested positive for COVID 19, and out of the positives, 95% of those with active infection identified as Hispanic/Latinx. Furthermore, 82% of those who tested positive also reported having been financially affected by the economic fallout of the pandemic and only 10% reported having the ability to work from home [3]. Latinos are the largest ethnic minority group in the USA; in 2014, Hispanics comprised 17.4% of the US population (55.4 million), as time continues to pass, this percentage is expected to increase to 28.6% (119 million) by 2060 [4]. Under the strain of a relentless infectious disease pandemic, these statistics rang true in San Francisco where people suddenly faced the decision of whether to divert resources to preventative health care or more proximate essential needs like food and shelter.
Under the shelter in place order many Community based organizations (CBOs) in the neighborhood were forced to shut down. Together they provided essential medical, legal, and economic support for the community. The exclusion of CBOs as essential businesses left the community with little to no resources in unprecedented adverse circumstances. Many community members lacked access to food, healthcare, legal services, housing support, and unemployment support. As the number COVID-19 cases grew in the Latinx community, the number of medically underserved and uninsured persons surged as well. Clínica Martín-Baró rose to the occasion by revamping to a virtual model and continuing to aid against the most pressing health needs of the community. In a time when emergency rooms are being described as frontlines in the war against a communicable disease like COVID-19 it is absolutely imperative to center the needs of the undocumented community. This community was an afterthought in every facet of the pandemic: education/outreach, testing, PPE, and now vaccines. Thus out of this necessity to maintain our presence of solidarity with those unable to engage in public streams of health care we launched a virtual tele-health initiative called “TeleClinica.”
As a clinic that primarily focuses on supporting a monolingual Spanish speaking, migrant, low-income population we came to realize that becoming virtual would create some substantial barriers as to how we would continue to serve the community during this relentless health and economic crisis. Our greatest challenge in transitioning from a physical clinic to a virtual one was having to transform our operations including coordinating clinical visits, laboratory, pharmacy and referral follow-up all to be entirely facilitated online with particular attention to adaptability and ease of use for our patient population with limited access to technology, transportation, and resources. Shortly after launching our telehealth initiative in August 2020 we performed a wellness check campaign where we attempted to call 36 patients, astonishingly out of 36 attempted calls 17 phone numbers were found to be disconnected due to non-payment of phone bills. We believe this observation was a consequence of the substantial economic losses, food insecurity, rent payment difficulties, and job insecurity associated with the high levels of unemployment accompanying the shutdown of economic activity. Our collective responded by stationing ourselves in the community and performing health outreach at food distribution sites in the neighborhood. As a student run free clinic we were able to support a total of 178 telehealth encounters between July and December 2020. In the context of a public health emergency our experience operating a virtual student-run free clinic allowed us to appreciate just how much the local community was disenfranchised during the pandemic.
Community health organizations such as Clínica Martín-Baró were established as a grassroots band-aid solution to systemic issues in our healthcare system. We are a group of concerned community members that came together to support a vulnerable population in ways our institutions simply would not. In the context of an infectious disease pandemic and with the shutdown of many public facing organizations, Clínica Martín-Baró was forced to reconcile the essential nature of its services to the public without bearing the label or privileges of an essential business and with little institutional support. We learned just how much vulnerable communities rely on student-run free clinics for support and how the COVID19 pandemic has widened care gaps for this population.
There are considerable obstacles to operating a free clinic in a virtual manner. Clinic members have multiple calls with patients throughout the week to elucidate social and medical concerns. Despite the seemingly inconvenient schedule of multiple calls there is no other option for most of the patients served in this space. The persistence of the volunteers to find any means to remain present and engaged with the community of patients is remarkable. It is our moral imperative to maintain access to basic medical care to keep solidarity with our most vulnerable community members giving them options to the emergency rooms for preventable health conditions. In finding a way to safely operate during the COVID19 pandemic we radically reimagined what a student-run free clinic can look like and realized the significance of student organizing in supporting community health.
Student-run free clinics serve the community in a unique way by providing healthcare in a community rooted manner. We are a collective that has gained the trust of the local community through years of outreach and organizing. The Spanish speaking, undocumented, low-income community we serve has never been supported by traditional healthcare insitutions. CMB’s outreach efforts often represent the first healthcare visit in years for many undocumented people. During the COVID19 pandemic this population was largely excluded from much of the aid provided by legislative measures. By creating a virtual student-run free clinic, CMB safely provides an essential service to a medically underserved population that has been particularly impacted by both the health and socioeconomic consequences of the COVID19 pandemic.
Despite not being recognized as an essential entity, student-run free clinics provide an essential service to vulnerable communities. Undocumented communities have consistently been denied adequate access to health care, leaving entire communities;regardless of ethnicity and race, to deal with chronic, debilitating and preventable health outcomes.Student run free clinics serve the community by providing healthcare in a community rooted manner, understanding that trust and communications are key to comprehending and responding to the needs of the community around them - it is this very notion that allows community to heal , which institutions have not been able to do.The COVID19 pandemic has strained the order of society and we have been forced to ponder what is essential for our communities. The truth of the matter is that we should not need to be essential; access to health care should be a right. However, until access barriers no longer exist, we are essential, out of necessity, to support the health needs of our most vulnerable communities.
To end, this work could not have been possible without the support of Clinica Martin Baro’s volunteers. The volunteers are select San Francisco State University (SFSU) students recruited from the College of Ethnic Studies as well as University of California, San Francisco (UCSF) medical students, and faculty.
References
1) Health Insurance Coverage | City Performance Scorecards. (n.d.). SF.Gov. Retrieved August 3, 2020, from https://sfgov.org/scorecards/public-health/health-insurance-coverage
2) San Francisco Community Health Needs Assessment 2019 Report. (2019, May). SFDPH. https://www.sfdph.org/dph/hc/HCAgen/2019/May%207/CHNA_2019_Report_041819_Stage%204.pdf
3) Fernandez, E. Weiler N. (2020, May 4). Initial Results of Mission District COVID-19 Testing Announced: Latinx Community, Men and Economically Vulnerable Are at Highest Risk. UCSF.Edu. https://www.ucsf.edu/news/2020/05/417356/initial-results-mission-district-covid-19-testing-announced
4) Velasco-Mondragon, E., Jimenez, A., Palladino-Davis, A. G., Davis, D., & Escamilla-Cejudo, J. A. (2016). Hispanic health in the USA: a scoping review of the literature. Public Health Reviews, 37(1), Abstract. https://doi.org/10.1186/s40985-016-0043-2
5) Hutchison, J., Thompson, M. E., Troyer, J., Elnitsky, C., Coffman, M. J., & Lori Thomas, M. (2018). The effect of North Carolina free clinics on hospitalizations for ambulatory care sensitive conditions among the uninsured. BMC Health Services Research, 18(1), Abstract. https://doi.org/10.1186/s12913-018-3082-1
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