Dr. Brennan is an Associate Professor at the Graduate School of Meharry Medical College, one of the historically black medical schools in the US. This book grows out of her work as editor of the Journal of Health Care for the Poor and Underserved; almost all of the articles were previously published in this journal.
Why do free clinics exist and why do we need a book about them? Isn’t the Affordable Care Act (ACA, Obamacare) going to provide health insurance to all Americans?
The ACA will dramatically reduce the number of uninsured Americans from the estimated 46 million in 2010 (when the bill was made law) to an estimated 23 million by 2019 (when it will be fully implemented). Seven of these 23 million will be undocumented workers. The refusal of many states to accept federal dollars for Medicaid – if continued – will mean that the number of uninsured will probably be significantly more than 23 million.
The creation of “free clinics” to provide services to those without access to health care has a long and rich history, some of which has made it into the popular imagination: the Gesundheit Institute, a free hospital associated with Patch Adams; the Common Ground clinic, created after Hurricane Katrina in New Orleans; and San Francisco’s Haight-Ashbury’s free clinics. What do free clinics accomplish? In 2001 it was estimated that “only about 650,000” of the 41 million uninsured Americans got care at free clinics. The author’s comment that “[m]uch literature posits that free clinics exist as a short-term solution to serve victims of a failing health care system, […] even the most successful clinics cannot provide a viable long-term solution to disparities in health care.” Yet free care to 650,000 people is an impressive accomplishment and a tribute to the survival of a service ethic in an increasingly corporatized medicine.
We know a fair amount about the functioning of free clinics from published articles and books, as well as from organizations such as the National Association of Free and Charitable Clinics and the Association of Clinicians for the Underserved. But this data is not systematically collected. Brennan’s book does a major service in its first chapter by providing a comprehensive review of what we do know based on a rigorous review of ninety articles. Free clinics see a population that is “disproportionately low-income, female, uninsured, immigrants, or minorities.” Diabetes and mental illness are common problems; in fact, mental illness – related to harsh social conditions – is nearly universal. Money to run the clinics is pieced together from a variety of sources: individual donations, institutional funds, corporate and charitable donors, and (minimal) state and federal dollars. Clients are often referred to other parts of the health care safety net. Services provided tend to focus on prevention, education and providing access to medications. This review closes with a long list of potential research projects regarding free care.
Free Clinics offers us a rich selection of papers fleshing out the details of this review. The primary audience will be health care providers and medical educators; nearly half the book is devoted to student-run clinics. The book’s chapters allows the reader to get a good sense of the practical problems of free clinics, the challenges faced by them, and their limitations. If you want to work in (or set up) a free clinic or a student rotation in poor/underserved medicine, this book has much information that will be useful to you.
But free clinics – by their very existence – raise a host of interesting social questions that will engage a broader audience.
Let us begin by considering the important place that free clinics play in medical education. We have no less than seven student-run free clinics in New York City, one of the cities with the most advanced health care infrastructure in the world. The chapters in Brennan’s book stress the need for institutional support and supervision for projects that are typically initiated by enthusiastic students. These clinics can be associated with community activism, such as the 2002 Candlelight Vigil for Uninsured Georgians organized by students from Emory and Morehouse. Students need support to assure that a stable setting is developed that provides high-quality care for the patients and an appropriate educational experience for students.
But what is the real place for such free clinics within academic medical centers, which are increasingly indistinguishable from large for-profit businesses? Is this simply an interesting pastime carried out by a few “progressive” students and their faculty mentors? An activity that makes the institution look good but is entirely peripheral to the real mission? What does it say when a homeless person is rejected in the outpatient clinic but seen by a student outreach team on a van or in a shelter?
The existence of free clinics highlights the inadequacies of the current system, most specifically the inability of our profit-based institutions to provide health care for all. The fact that such institutions are free also creates opportunities to “do things differently” and not simply to recreate the existing health care model. This is, for example, an explicit goal of the Gesundheit Institute: “a project in holistic medical care based on the belief that one cannot separate the health of the individual from the health of the family, the community, the world, and the health care system itself.” Brennan’s book concentrates on the role of free clinics “as a pillar of the health care safety net” and this is entirely appropriate. But there are potentially more emancipatory roles for free clinics. Many were created by social movements and thus embody particular political ideals. A recent book by Alondra Nelson – Body and Soul: The Black Panther Party and the Fight against Medical Discrimination – traces the fascinating history of free clinics within the Black Panther Party.
As the Greek health care system has imploded in the past few years, physicians in Thessaloniki, Greece’s second largest city, partnered with the local community to create the “Social Clinic of Solidarity”, a free clinic that was originally designed for refugees but now serves the entire community. This clinic involves over 200 doctors and provides general medical care (including pediatrics), dental services, physical therapy and a social (i.e. free) pharmacy.
So, it doesn’t seem like free clinics are going away anytime soon. We can thank Dr. Brennan for providing us with a road map as we move forward, as well as material that should foster a debate on where our health care system is going.
[As a courtesy to our guests, please keep comments to the book and be respectful of dissenting opinions. Please take other conversations to a previous thread. - bev]