“If you are having difficulty breathing, go to an emergency room or call 911.”
This previously routine advisory made its last appearance in a Dec. 18 news release by the Los Angeles County Department of Public Health, announcing that county hospitals had exceeded 5,000 patients being treated for Covid-19.
In an alert issued five days later, the department admonished health care providers, “Do not send patients to emergency departments unless absolutely medically necessary.”
This scenario is not unique to Los Angeles. It is playing out in hard-hit cities and counties across the country.
Call your community health center.
Community health centers can play a crucial role in reducing the burden of the Covid-19 epidemic in the difficult winter months to come. They can serve as critical safety valves at a time when acute care hospitals and emergency rooms are saturated with patients. As a primary care physician working at a community health center in downtown Los Angeles, who has cared for so many frightened patients and their families, I know this all too well.
Community health centers are where the action is
The scourge of Covid-19 continues to take its greatest toll on people of color, especially those living in areas with high concentrations of large, multigenerational families. While there is growing concern about the overwhelming caseloads of tertiary care hospitals, the most pressing need for patient care is in those local hotspots where new infections are bounding upward.
In the map below of Los Angeles County, the darkest shaded areas are hotspots where the epidemic has been spreading fastest. The black dots show the locations of 345 patient-care sites of the 64 clinics of the Community Clinic Association of Los Angeles County.
That means people who live in these hot spots who realize their food tastes like cardboard and have a fever or cough have someplace nearby to go.
Los Angeles County is hardly a special case. Across the U.S., community health centers are located in areas where the epidemic is surging among African Americans, Hispanic Americans, Asian Americans, Native Americans, and other groups.
Here are some of the ways community health centers could respond rapidly to the pandemic, if only they were given adequate resources to do them.
Perform high-volume testing for Covid-19. Testing people for Covid-19 needs to be more proactive. We can’t continue to sit back and wait for symptomatic people to come through the door. Many workplaces and educational institutions have engaged in routine testing of asymptomatic people. Community health centers need to be the next locus of routine testing, with a focus on bringing in all household members at the same time.
A lot has been said about the importance of patient-centered health care. Community health centers can go one step further to deliver family-oriented care. I have heard the same story far too many times: A socially mobile young adult imports the infection into the household, and then everyone else, including grandma and grandpa, get sick and someone ends up in the hospital. Community health center providers know which families are at the highest risk for this potentially deadly scenario and are positioned to proactively bring in entire families for routine testing.
Use telemedicine technology to rapidly respond to patients’ inquiries and concerns. Providers at community health centers have the knowledge to answer questions about the accuracy of Covid-19 tests, the amount of time a sick person remains infectious, the risks of complications during the second critical week of the disease, and more. We are ideally positioned to answer questions as to whether Covid-19 can cause diarrhea, rashes, earache, back pain, and anxiety due to a low level of oxygen.
We have the know-how to counsel patients one-on-one about how the inflammatory symptoms of Covid-19 can last long after virus is gone and the credibility to advise patients with diabetes or high blood pressure who want to know whether to keep taking their medicines while they’re sick. Telemedicine allows us to answer these questions without having to bring patients and other family members into potentially risky waiting areas.
Respond rapidly to patients who are at risk of deterioration. Blanket rules about calling 911 are a poor substitute for the intelligent, case-by-case decisions of physicians, nurse practitioners, physicians’ assistants, and nurses who know their patients and who can advise a patient when it’s time to go to the emergency department. A sick patient can wait eight hours in the emergency room to get a chest CT scan confirming Covid-19 pneumonia, when an astute clinician at a community health center can make that diagnosis by observing the pattern of her patient’s breathing as she talks via smartphone camera.
Distribute pulse oximeters to patients and teach them how to use them. The pulse oximeter, a simple tool for measuring the amount of oxygen in the bloodstream, is widely acknowledged as an essential tool in the outpatient evaluation of patients with Covid-19. Community health centers are ideally situated to distribute these devices to the patients who most need them. I often call patients to find out whether that number is going up today or down, and advise the patient or his or her family how to adjust the flow rate of their portable oxygen machine accordingly.
What we need to accomplish this vital task isn’t a small grant here or there giving a few dozen devices to a community health center. We need an abundance of them — tens of thousands.
Provide timely outpatient treatment to high-risk Covid-19 patients. There is growing evidence that monoclonal antibody infusions need to be given as early as possible to high-risk patients, while the virus is still surging throughout the body. These treatments may be ineffective if they aren’t given until someone is so ill as to need hospitalization. The same may be true for the antiviral drug remdesivir.
Community health centers are well-situated to identify those at high risk of developing severe Covid-19 and to treat them as soon as possible on an outpatient basis. Instead of thinking about providing treatment to a patient on a gurney parked in the hallway of a packed hospital, think about a health-center-based nurse administering a lifesaving infusion to a 70-year-old with diabetes within a couple of days of his feeling feverish and achy.
Become the most important vaccination stations. Some populations, including African Americans and Hispanic Americans, are more reluctant about getting the new Covid-19 vaccines than white, non-Hispanic Americans. As the criteria for vaccination are being relaxed throughout the country, those with the least resources will likely find themselves at the back of the queue. Community health centers are ideally situated to solve both of these critical problems. We’re already calling our high-risk elderly patients, who have no cars or no internet access, and bringing them in vans to our health center for their vaccinations.
If our federal, state, and local governments diverted substantial additional resources to community health centers, we’d have a real chance at putting out the flames of Covid-19 before we reach a half-million dead.
Jeffrey E. Harris is a primary care physician at Eisner Health in Los Angeles and a professor emeritus at the Massachusetts Institute of Technology.