BIRMINGHAM, Ala. (AP) — The afternoon was hot, the damp air thick with the threat of rain. But the cracked parking lot behind the newly-opened Cahaba Medical Care clinic in Birmingham's West End neighborhood was full. And the band was just cranking up.
Dr. Ernestine Clements grabbed nurse manager Veronica McDonald and receptionist LaTonya Greene and headed for the front of the makeshift stage. Clements was about to graduate from her residency program and was in the mood to celebrate becoming a full-fledged doctor in the community where she'd grown up.
Soon Clements was joined by a group of nurses and physician's assistants at the stage, while the band's lead singer serenaded them. Nearby, kids from the neighborhood were jumping in bouncy houses set up on the clinic lawn along Tuscaloosa Avenue. Adults sat in the shade of umbrella-covered picnic tables, eating barbecue and chatting with medical staff.
Murleen Simon watched it all from over near the food tent where doctors and nurses were handing out free hot dogs and bottles of water.
"There she goes! There goes my doctor right there," she called, pointing to Clements in the group of women that were laughing and dancing at the stage.
Nearly all of Alabama's 67 counties have a shortage of primary care doctors, which treat a wide variety of patients and conditions. But even in Birmingham, home to more hospitals than any city in the state, some communities like West End face barriers to getting basic healthcare.
"As saturated as downtown is with hospitals, it is lacking family medicine and primary care that takes Medicaid, that takes the uninsured, that takes care of the most in-need population," said Dr. Shelley Waits, a physician at Cahaba. "This is a role that needed filling."
Simon, a longtime West End resident, is a new patient at Cahaba. She said she'd found out about her neighborhood's new clinic from a flier at her local church.
"When I saw that pamphlet, I said, 'Jesus, this is you,'" she explained. She had liked her previous doctor, but to reach his office she had to take a long, bus ride, and then walk quite a ways along the side of the road. Often the bus was so crowded, she said, that she had to stand the whole way there.
So she walked into Cahaba a few months ago and said she loves it.
"I prayed to God that they'd come," she said.
Rural to urban care
Cahaba hosted the free community festival in June to let their West End neighbors know they were open and ready to see patients, regardless of their insurance status.
The West End clinic opened in January of last year and now has a team of more than a dozen doctors and nurses, including a handful of doctors working in its residency program.
The clinic is part of Cahaba Medical Care, a group of Alabama clinics that are Federally Qualified Health Centers, which means they receive federal funding to provide primary care in underserved areas.
Cahaba is headquartered in Centreville, about an hour's drive west in rural Bibb County. Cahaba is directed by Dr. John Waits and Dr. Lacy Smith, who received recognition from the governor's office last year after reopening the labor & delivery department at the rural hospital in Centreville. In the past few years, Cahaba has opened five new clinics in underserved communities in central Alabama.
The West End clinic is the first to open in an entirely urban setting.
West End has a reputation for being one of the most dangerous neighborhoods in Birmingham. It saw 14 homicides last year, the second most of any Birmingham community during a year in which the city saw a record number of killings.
A month after the clinic opened, two young men were gunned down in an apartment building across the street. Four blocks away, an Honor Roll student was killed in November after someone fired more than 50 bullets into the home where she was sleeping.
But West End is also a neighborhood with a strong sense of place, with community programs and thriving urban ministries and people who look out for each other.
It's a neighborhood Clements knows well. She grew up in West End.
"I didn't see a lot of doctors growing up," she said. "We didn't have our own doctors; we went to the health department a lot for primary care and vaccinations."
When Clements was younger, her mom suffered from drug addiction. One day, as her mom was leaving the house to go get high, Clements stopped her.
"I was like, 'Nope, I'm coming with you. We're going to fix this together.'
"That was her turning point. From then, she was like, 'You're going to be a doctor because you saved my life.'"
Clements scored high enough to get into a magnet program in Birmingham City Schools. She didn't know anyone in her neighborhood who'd graduated from college.
"It was a process, trying to figure out how a girl from West end can get to be a doctor," she said. But she was able to get scholarships and later became the first college graduate in her family.
She went to medical school in Ohio, but her heart was back in West End.
It's a community with a high Medicaid population. Most everyone else has little or no insurance. Because of that, many go to the ER for primary care and to manage chronic conditions, rather than for emergency medical attention, said Clements. Lots of times, they just don't go anywhere.
"Where I grew up, sometimes you had to decide between your health and being able to put food on the table," she said. "I know how that felt."
Most of the hundreds of residency programs in the United States are based in hospitals, which are typically located in urban centers. Residency is the last step before a doctor can fully practice medicine, a three-year program that follows graduation from medical school.
But a few residencies, about 57 nationwide, are Teaching Health Centers like Cahaba. Rather than training doctors in a hospital setting, these programs train primary care or family medicine physicians in community clinics, often in low-income or marginalized neighborhoods.
More than half of graduates from these types of programs go on to practice in undeserved rural and urban areas, compared with just 26 percent of graduates from traditional programs, according to the American Association of Teaching Health Centers.
Teaching Health Centers help fill a need. Alabama has one of the lowest percentages of primary care physicians in the country. Nearly 10 rural hospitals have closed across the state in the last 10 years. Most of Alabama is designated as a medically underserved area, according to the Alabama Department of Public Health.
But even though these programs train doctors to work in the areas where they're critically needed, the funding for them is shaky.
Traditional residency programs are funded primarily through Medicare, but Teaching Health Centers get their funding through the Health Resources and Services Administration. Congress has to renew that funding every two years.
Which means that every time there's a budget showdown in Congress, every time the government shuts down over funding talks, Teaching Health Centers are in jeopardy. That happened last fall, when the government shut down and federal funding halted just as Clements was entering her final year at Cahaba.
Luckily it was eventually renewed, but it was a tense time, she said. Cahaba's West End clinic absorbed some doctors and residents from a Teaching Health Center in Memphis that closed earlier this year due to funding problems.
Making it out
Veronica McDonald vividly remembers being a "clinic kid" when she was growing up in West End. When her family had to see a doctor, her mother would pack a lunch because she knew they'd be there most of the day, waiting to be seen.
"I remember being there and feeling like I didn't matter," she recalled. "It was almost like I was invading their space, like I was an inconvenience to them.
"I remember looking up at my mom and I remember thinking, 'Why are you letting them treat you like that? Why is this OK for them to talk to you that way?'"
After graduating West End High School, McDonald moved away and spent the next 20 years working as a nurse. She came back to West End in February when she joined the staff at Cahaba as nurse manager.
West End residents shouldn't have to see "making it out" of their community as the only way to survive and thrive, she said.
"I'm very particular about West End," she said. "I went to school and got and education, but everybody doesn't get out. Should everybody have to leave a place in order to get better?
"I want people to come here because I want them to know that they matter," she said, "that they are not what they do, they are who they are. It's OK to be broken. It's OK to be sick. That doesn't define who you are. You just need help, and we're here to help."
'We're here to stay'
Despite the constant threat of funding cuts, the clinic is growing. In the next few weeks, it will open a pharmacy there in the building, where patients can get discounted or free medication. A dental clinic is planned for another wing.
But optimistic goals are something the community has seen before. The one-story brick building on Tuscaloosa Avenue has been several different clinics over the years. Some locals have been skeptical, said Clements, that Cahaba is here for good.
"They've had people move in, but then in a few months they're gone," she said. "We're here to stay."
Some of the doctors at the clinic have moved into homes in the West End neighborhood. McDonald said it's not unusual for medical staff to eat lunch at churches and shelters in the area to get to know their neighbors better.
Cahaba uses a sliding scale to charge patients as little as $5 or $10 for a visit. There are some diagnostic tests, like EKGs and mammograms, that can be done on site. The clinic employs social workers to help patients navigate Medicaid and insurance, and offers food assistance and other non-medical supports.
"When I grew up, I rarely went to the doctor, and we sometimes didn't have food to eat," said Clements. "We sometimes came home and there was no power. So I wanted to be able to come back and provide some of that social support to the community, and I can do that here."
When the clinic opened, it convened a stakeholder board of local pastors, community leaders and residents to help guide and advise.
One of the biggest concerns the board had recently was that not enough local residents knew the clinic was open, or that doctors would see patients regardless of insurance status.
So Cahaba threw the neighborhood block party.
"Sometimes medicine is not the first thing on their mind," said Clements of her neighbors. "We want to get Cahaba's name out there, to tell people, 'We want you here.'"