‘We’re in a crisis’: Richmond tests public health innovation in health care desert

When Joe Griffin’s aunt suffered a stroke last year, she was lucky to be in Richmond.

The city’s Kaiser hospital has the emergency capacity to deal with strokes. In fact, it has a specialty center dedicated to treating that medical emergency. But when the stroke ended and she needed follow-up care, Griffin’s aunt didn’t know where to go. Growing up, his family was uninsured and relied on Doctor’s Medical Center, then known as Brookside Hospital in San Pablo, for medical care. But the center had closed.

“[Kaiser’s] incentive is to stabilize, which is great,” Griffin said. “But where do you go after that?”

Today, there’s still LifeLong Medical Care, which operates three of Richmond’s four federally qualified health clinics. “They do what they can,” Griffin said. But those alone can’t satisfy the medical needs of such a large population, many of whom have insurance other than Kaiser, are on Medi-Cal, or lack insurance.

“There’s a lot of pressure for capturing those non-Kaiser members, and there’s so many non-Kaiser members in Richmond,” Griffin explained.

Meanwhile, last year, one of the nearest hospitals along the Interstate 80 corridor, Alta Bates in Berkeley, announced plans to close. Despite policy-makers’ efforts, the closure is moving forward. And while Sutter Health has stated it intends to maintain Alta Bates’ emergency bed capacity at its Oakland campus, the region will still lose hospital beds. Safety-net providers such as LifeLong, which serves any patient regardless of ability to pay, will pick up the slack.

But according to Dr. Desmond Carson, a LifeLong Urgent Care San Pablo physician, the West County area is ill-equipped to deal with the medical needs of its 400,000 residents.

“It’s horrible,” Carson said of the landscape of health-care access in Richmond and west Contra Costa County.

Griffin is now a Ph.D. student in public health and city planning at UC Berkeley, and the head of research for Richmond’s park-building nonprofit Pogo Park. He is both intimately familiar with the city’s health-care situation — and is one of the leaders trying to solve it.

A challenge is that, despite its many ailments, Richmond doesn’t have a public health department working on cures. So, instead, Griffin and his colleagues, including his advisor, professor Jason Corburn, look to the city planner to be the city’s doctor.

This innovative approach is known as Health in All Policies: A program that looks at each municipal department and policy, from transportation to education, through the lens of health.

Richmond’s general plan, the state-mandated blueprint for each city’s long-term land use, now contains an actual prescription for the health of the community as a whole.

The question remains, however, whether this new approach — looking at the ways in which the city fosters or neglects health — can address what’s ostensibly a crisis of access.

Offering a prognosis for this new approach, Carson considered the way he treats his patients: Any time an individual takes a test, Carson tells them that the possible result can be anything. When it comes to Health in All Policies, he does the same: Rather than assessing what may be, he looks at the results in front of him, and says that, at this particular moment, he can’t foresee what the future holds, or what the results of this new approach may be.

All he can say is that the landscape for health in West County is not good. Or, put simply, it’s “fucked up,” Carson said.

An uphill battle

Last year, when Alta Bates in Berkeley announced it would close due to what the hospital cited as seismic safety requirements, the decision felt like an aftershock in Richmond.

The community was still reeling from the closure of Doctors Medical Center in 2015. “We’re seeing closures of urban hospitals around the state and around the country that are jeopardizing emergency medical care in our communities,” Supervisor John Gioia said this past September, advocating for legislation, Senate Bill 687, that sought to keep Alta Bates open. The state bill passed both houses of the Legislature, but Gov. Jerry Brown vetoed it.

Before its closure, 42 percent of ambulance traffic in the area went to Doctors Medical Center, according to a report prepared by Contra Costa Health Services in December 2014.

After, a large amount of that traffic, unsurprisingly, went to the nearby Kaiser Richmond; its emergency room traffic increased by 50 percent. But numbers at Alta Bates also spiked. Just four months after Doctors Medical Center closed, the average daily ambulance transports coming to Alta Bates from Contra Costa approximately doubled, according to a report from the Doctors Medical Center regional planning group.

According to Contra Costa Emergency Medical Services director Pat Frost, ambulance hours of operation increased and response times in Richmond improved since the closure. The county’s annual EMS report indicates that Richmond ambulance response times are expected to beat the industry standard of 11 minutes, due to the high population density.

Still, the distance those first responders must travel has increased. With more changes on the horizon, advocates are worried.

Jim Maddox is a retired paramedic, who started his 30-year career in Richmond. “It is a challenge, because now you’re transporting patients far away to Alta Bates, which is now closing,” Maddox said. “Any time you take a paramedic unit out of an area far away that reduces the amount of ambulances available for the next call.”

Maddox thought the closure of Doctors Medical Center would be so dire that he actively opposed it and campaigned for measures aimed at keeping the bankrupt facility afloat. His face once appeared on billboards in favor of a bond measure that would have supported the medical center, he said.

The bottom line is that the low number of hospital beds per person in Richmond is already a challenge for emergency medical care of individuals. If there were to be a crisis — for example, an earthquake or a fire the magnitude of the north bay fires — “we would not have the beds to treat those people,” Carson predicted. “Kaiser could not do it, and I’m not talking bad on Kaiser; they’ve helped us a lot.”

Kaiser has already been tested by the increased demand after Doctors’ closure. It invested millions in expanding its services, roughly tripling the number of general admissions since 2014, according to Jeff Collins, senior vice president and area manager, Kaiser Permanente East Bay Area. Still, Kaiser’s Richmond Medical Center is a small facility, just 50 beds, and Collins said in an email the organization remains concerned about the community’s overall capacity to provide care.

Emergency care was just one aspect affected by Doctors Medical Center’s closure. There were also people who relied on that emergency room for primary care.

While Kaiser, like any hospital, is legally obligated to care for patients in an emergency situation, it remains a closed system. Kaiser subcontracts with the Contra Costa Health Plan (CCHP) to provide continuity of care for patients who were on Kaiser in the 12 months preceding their switch to Medi-Cal. In West Contra Costa County, that amounts to about 10,585 patients, as of September 2017, according to Patricia Tanquary, CEO of CCHP, the managed care plan that covers 188,000 Medi-Cal enrollees in the county.

Still, Tanquary believes access is not a problem for patients covered by CCHP. There’s also federally qualified clinics in the county, such as La Clinica de la Raza and LifeLong, and CCHP contracts with 6,000 primary care providers, Tanquary said.

She acknowledged, however, that emergency room access is a separate issue.

In Richmond, where Kaiser has a limited ER capacity, Tanquary said she works with the hospital every week to minimize members going there for care.

The people who went to Doctors for primary care, like Griffin’s aunt, have likewise been diverted. LifeLong, which operates three clinics in Richmond, saw its patients nearly double since 2014, when it saw just under 11,000. In 2015, after LifeLong closed, it saw nearly 21,000.

According to LifeLong spokesperson Helen Pettay, while LifeLong clinics see 40 to 50 patients per day, Doctors Medical saw 80 to 90.

Lucinda Bazile, deputy director of LifeLong Medical Care, says that while the urgent-care facility fills some gaps, places like Kaiser are likely inundated.

“Regardless of whether we’re there or not, we need to have hospital services,” she said. “People should not rely on the emergency room, because that takes away from people who have emergency needs.”

She added that it would hurt the community if Alta Bates in Berkeley closed.

Carson summarized the struggles for emergency care in his characteristically blunt fashion: “We’re in a crisis.”

A crisis of conditions

Carson worked at Doctors Medical Center until April 13, 2015, a week before it closed for good. The next day, he served patients across the street at LifeLong’s newly opened urgent care facility. That quick transition of patients to care of a nearby facility, albeit a smaller one, was just one of the many ways providers and policy-makers in West County addressed the loss of more than 200 beds with Doctors’ closure.

Stakeholders floated the idea of putting money into the financially sinking hospital. But in the end, it was determined that, at best, the funding would be a temporary solution, perhaps keeping Doctors open another year or so. Instead, LifeLong opened its San Pablo Urgent Care clinic across the street. Kaiser, recognizing the need, put $3 million into opening that LifeLong clinic, but the facility is just five exam rooms, not nearly enough to fill the gap.

“That sort of crisis stage has passed a little bit, but I do think it needs to be part of the continuing conversation,” City Manager Bill Lindsay said of ongoing efforts to address West County’s lack of hospital access.

The loss of a facility like Doctors would be a big hit to any community’s medical care providers. While Carson offered the examples of the recent fires in Napa and Sonoma counties, or an earthquake to back up assertions about the challenges faced in Richmond, the existing system would hardly need a catastrophe to push it to its limits. The existing environment might be unhealthy enough, even without extra smoke in the air.

Maintaining well-being is just one piece of the picture, but the need for access is even more crucial for sick people who need treatment. Unfortunately, in Richmond, the environmental factors influencing health, and consequentially rates of certain diseases, are not good.

For example, children in Richmond are hospitalized for asthma at nearly twice the rate of children elsewhere in the state, according to Contra Costa Health Services. That disparity deepens along racial and class lines. In Contra Costa, African-Americans are four times more likely to be hospitalized for asthma, and the communities identified as at risk in for the disease in a 2003 study are largely low-income communities of color, according to CCHS’ website.

While many opponents of the nearby Chevron refinery blame the facility for these trends, the connection is unclear. When it comes to asthma rates, scientists remain unable to separate the influence of air pollutants, such as fumes or chemicals, from other allergens, like dust or pollen. Still, there are health consequences of such proximity to an oil refinery: A 2012 Chevron fire sent more than 15,000 nearby residents to the hospital.

Refinery incidents aren’t the only events that can damage residents’ health. Gun violence is another problem, especially in certain neighborhoods. Though violence has declined by 71 percent in the last 10 years, there were still 22 gun-related deaths in 2016, according to the Office of Neighborhood Safety (ONS).

Richmond also has been called a food desert: Approximately a third of the city lives in a “critical food access area,” according to the nonprofit Social Compact, which conducted a grocery gap study. The term ‘critical food access area’ essentially means that, relative to the rest of the community, these areas lack access to healthy food and grocery stores.

In Contra Costa County, more than half of adults are overweight or obese. Though its obesity rate is slightly less than the statewide number, it is higher than the greater Bay Area’s rate. Obesity and its related diseases (diabetes, hypertension, heart disease) are strongly correlated with race and socioeconomic status.

Certain neighborhoods are more affected by these health problems than others, and these are also the ones struggling the most to get health treatment.

Richmond’s 2017 Community Survey indicated that residents in the neighborhoods of Shields Reid, Iron Triangle, Coronado, Santa Fe, Atchison Village, and Belding Woods were far less likely to rate their access to affordable quality health care, health and wellness opportunities, healthy food, and preventive services positively than residents of other neighborhoods. In Richmond overall, no more than 30 percent of the population rated any of these four measures positively.

The discrepancies between various neighborhoods’ responses to questions about access to health care and other resources demonstrate the influence of location on one’s health.

The city’s Health in All Policies, a first-of-its-kind approach to urban planning and public health, strives to address those social and geographic factors.

“They have this saying, that your ZIP code is more important than your genetic code,” Mayor Tom Butt said at a Pogo Park event in September. “You can have the best genes in the world, but if you’re in an environment where people don’t care about each other — and they don’t take care of each other and they don’t take care of the environment and they don’t take care of the neighborhood — then ultimately your health is gonna suffer.”

Lindsay described the situation more bluntly: People born in Richmond don’t live as long.

In merging the seemingly disparate fields of health and city planning, city officials hope that focusing on health equity in all their decisions will improve resident well-being and their longevity, Lindsay said.

An ‘upstream’ solution

Richmond’s Kaiser Medical Center sits at the intersection of Nevin Avenue and Harbour Way, on the eastern edge of the city’s Iron Triangle neighborhood. During the second week of October, the sidewalks outside of Kaiser were the only part of the neighborhood that showed signs of human life. Smoke loomed over the city, from the fires on the other side of the Carquinez Strait, and residents were only leaving their homes to pick up breathing masks from the Kaiser hospital, which had already given out many more boxes than on a normal day.

Farther south along Harbour Way, the Richmond Greenway Trail was all but deserted. The pathway, which runs from the Ohlone Greenway’s end in El Cerrito to the Bay Trail north of Richmond, doesn’t capture the L.L. Bean catalogue aesthetic one might hope for on a trail. Instead, the asphalt pathway runs adjacent to chain link fences, train tracks, and debris. On this smoky day, people paced hurriedly down the path to their destinations — there were no flowers to smell, even if they wanted to, just ash. But on a small stretch of the path, between Eighth Street and Harbour, that didn’t ring true. An older man stopped to enjoy the shade of a freshly-planted tree at Harbour-8 Park.

Just two weeks earlier, this block of park and pathway had been a center of celebration. Pogo Park, the Watershed Project, and the Trust for Public Land came together to commemorate the installation of new trees and a bioswale, a landscaping feature that can help remove air pollution, in the Harbour-8 land parcel. Griffin emceed the ceremony, where his boss, Toody Maher, the founder of Pogo Park, declared the gathering a sign of a “Richmond Renaissance.”

This site is just one of the ways Health in All Policies has begun to manifest itself in Richmond. Because the framework is enacted in large part through the general plan, which focuses on land management, the changes so far have largely been evident in the built environment, things like parks and walkable paths, said Gabino Arredondo, a management analyst for the city manager’s office.

This celebration of the Harbour-8 park was just one of the small victories Griffin hoped would mark the progress of Health in All Policies. Advocates, policy-makers, and researchers agree that, for the program to work, the community has to be invested in its success.

“Small wins after small wins,” Griffin said. “That’s what brought me back.”

According to Griffin, one problem with community development is that external sources misunderstand the community, which leads to broken promises. Health in All Policies, advocates hope, circumvents that problem through grassroots development.

“It was developed as part of a community-led and community-participatory process,” said Jason Corburn, a UC Berkeley professor of city planning and public health. “The Health in All Policies wasn’t something we dreamed up from Berkeley or whatever.”

He added that Richmond is unique because it may be the first city to implement Health in All Policies: In the past, it has been implemented through the county. According to Lindsay, only two cities in California — Berkeley and Pasadena — have health departments. So, when the California Endowment approached Richmond with the concept of integrating health and wellness into its general plan in 2006, the concept of a city executing health policy was fairly novel.

After that initial proposal from the Endowment, Richmond adopted a health and wellness element to its 2006 draft of the general plan. The initiative grew organically from there, as a part of partnerships between policymakers, funders, and community-based organizations.

“Even though it’s city-led, for me, when I think of the word city, it’s all the different groups and residents,” said Arredondo. “It’s not just me or the city manager’s office or the city manager or the council. It’s different partners.”

In 2014, the city council unanimously voted to codify Health in All Policies in the city’s laws.

Now, according to Lindsay, thinking of all policies through the lens of health is second nature. “It’s become, to a certain extent, a part of our DNA, the way we provide services,” he said.

Unlike Tanquary, a public health professional who can pull numbers about the county’s insurance enrollees off the top of her head, Lindsay doesn’t have degrees in public health. He is a city planner, meaning that his primary responsibility is land use and other policy. Now, he and his staff, as well as the staff of every other municipal department, use the words “health” and “health equity” in just about every meeting, he said.

“It was really apparent that all the issues we’re talking about in the general plan — like transportation, like open space, like land use, education, all of these things — had a dramatic influence on how healthy the community was,” Lindsay said. “That became the epiphany moment for me of ‘OK, we are in the health business.’”

This new “business” has cropped up in every department. The library offers digital health literacy classes to help people use trusted websites to access medical records and other essential information. The parks and recreation department has developed newer, less toxic ways to deal with pests in gardens.

The Health in All Policies framework also takes into account social factors that affect health, such as structural racism and socioeconomic status.

The RYSE Center is just one of the community groups taking on this impediment to health. At a training in October, they discussed ways to create safe spaces for young people of color in Richmond.

Urban Tilth also held a peaceful counter-protest recently, in response to the violence of white supremacists in Charlottesville and subsequent alt-right protests in the Bay Area.

The RYSE Center, Pogo Park, and Urban Tilth are just a handful of the nonprofits carrying out Health in All Policies. According to Griffin, nonprofits’ flexibility help speed up initiatives, which is why the city has partnered with so many of them, instead of implementing health-related activities itself.

Still, he acknowledged that relying on nonprofits to improve upstream health isn’t sustainable. According to Corburn, many of the innovative nonprofits operating in Richmond emerged from the process of planning Health in All Policies.

“The process itself helps build community organizations and capacity and that’s critical,” he said. “But, also, health equity can’t be achieved on the backs of the nonprofit world alone.”

And while a park might reduce the amount of people suffering cardiac arrest years down the line, the fact remains that the Kaiser hospital just a few minutes down the road from Harbour-8 lacks the capacity to help everyone who has a heart attack tomorrow.

And trees planted in that same park won’t rid the air of every particulate emanating from the Chevron Refinery a few miles north.

The mayor concurred. “Well, I’m not gonna tell you this counteracts Chevron. It doesn’t have a lot of effect on it,” Butt said at the Harbour-8 greening event. “People become more aware of and more interested in industries like Chevron, and they take more of an interest in what can we do to continue to clean up our air, and it also gives them hope.”

Right now, it’s still early in implementation to see the impact of Health in All Policies. There are new parks, programs to reduce violence, and other small changes that every city department has made.

As Griffin pointed out, it can also be difficult to attribute causality: If you see an increase in diabetes after Health in All Policies is implemented, does that mean the program caused diabetes? Or does it mean that efforts to get people enrolled in health care, so that they see a doctor, worked — and so more people are getting diagnosed?

Meanwhile, the closure of Doctors Medical Center and other recent obstacles to health care access in Richmond certainly don’t bode well for positive health outcomes as a community. In many ways, the new approach is conceptual:

In a city where health care resources are scarce, is it a more sustainable approach to treat the community as a whole?

Treatments not cures

Threats of an Affordable Care Act repeal have loomed large since the start of President Trump’s tenure. And Tanquary constantly fears the consequences of that political threat.

“I haven’t slept in a year,” she said. “It’s extremely concerning.”

While that never-ending saga continues in Washington, D.C. — and on Twitter — Congress’ inaction is possibly more concerning for those in the health industry. California and Contra Costa more specifically rely on the federal funding for qualified health centers, those that serve all patients regardless of ability to pay. Since the Community Health Center Fund expired on September 30, though, these clinics are now expecting to lose 70 percent of their federal grant funding in the new year.

While there is a bit of a stop-gap in funding, LifeLong, which serves 59,000 patients across Contra Costa and Alameda counties, stands to lose around $5 million if Congress doesn’t act to belatedly renew the Community Health Center Fund.

“It’s difficult, and we’re working in an environment of trying to determine if that happens what that would mean for us,” Bazile, LifeLong’s deputy director, said. “I can’t tell you what that would mean, but it would mean less services.”

Given that LifeLong has filled major gaps in primary care since the closure of Doctors Medical Center, these cuts could be disastrous for access in Richmond and West County. Still, LifeLong is plugging ahead, opening a new clinic in Pinole just last month.

Put simply, the political developments federally have many providers and stakeholders feeling like they are swimming against the current.

The ACA was a big part of how Health in All Policies developed, Lindsay said. After the program was initiated, through adding a health and wellness element to the general plan in 2006, the increase in coverage that came with the ACA’s implementation helped improve community health, creating new opportunities for the city to build on that progress.

According to Tanquary, the Medicaid expansion upped the number of recipients in Contra Costa by 72,000.

But while Richmond increasingly views health and health equity as central elements of any decision, the rest of the world still operates in a different paradigm.

Structural racism, economic inequality, and other larger social forces continue to influence residents’ health.

The question may not be whether or not Health in All Policies works at all, but rather if its influence can prevail over the forces working against well-being in Richmond, forces larger than the municipal government or the nonprofits it partners with.

Still, proponents of Health in All Policies hope that the recognition of the factors driving health other than medical care will mean better outcomes for the community.

“Health is not found in the hospitals or the health departments or clinics alone,” Corburn said.

While it’s hard to measure whether or not a community’s experience of social factors, like racism, for example, has changed, Corburn is keeping track to see if the community is changing.

Griffin agrees that Richmond is at a crossroads that will both test Health in All Policies as an approach and distract from the message.

“It’s trying to understand the frame and the conversation, and I think that’s what will be really interesting is to see how resilient these conversations are in the face of emergency,” he said. “The ability to stay the course will really show where Health in All Policies goes.”