Janelle Goetcheus had served the poor in Washington, D.C.'s inner city for seven years when this article appeared. She was born in Indianapolis, Indiana, and attended medical school at the Indiana University School of Medicine.
Dr. Goetcheus was the recipient of the 1984 A.H. Robins Award "For Outstanding Community Service by a Physician." She is known at Sojourners as not only a compassionate family doctor, but also a longtime trusted friend. The following interview took place at Columbia Road Health Services. —The Editors
Sojourners: Could you tell about the work you're doing here in the city and the people you are serving?
Janelle Goetcheus: I'm at three health services here in Washington. One is Columbia Road Health Services, which is a part of several forms of outreach of Church of the Saviour here in the neighborhood. Columbia Road came about with two goals. One, to reach out to those who are underserved medically, and two, to practice in a holistic model—not focusing just on physical needs but also on spiritual and emotional needs as a part of overall health. So we practice in a team, and many of the people who come here do not see just one of the practitioners, they also see one of the pastoral counselors, one of the social workers, or the nutritionist.
The people who come here to the health service are people who live in the neighborhood, many in low-income housing. In the mid-'80s, we saw a marked increase in the number of Hispanic refugees from El Salvador and other Central American countries. They arrived here needing housing, needing jobs, and needing health care.
We were seeing many pregnant young Hispanic women. They had no money, and many hospitals said that legally they didn't have to take them because they are not American citizens. They were very frightened because they ended up in an emergency room with a huge bill and a collection agency. One of the hospitals here threatened to turn over to Immigration and Naturalization Service one of our patients who owed money. To meet this need, we developed a nurse midwifery program and a low-cost delivery program through Providence Hospital here in Washington.
The other health services I was involved with are Community of Hope and SOME (So Others Might Eat). Community of Hope is housed in a building where there is emergency housing for homeless families. Many of the people who come there are persons from the immediate neighborhood. We see a lot of alcohol and drug problems.
SOME is a soup kitchen where between 500 and 600 homeless people are fed each day. The health service is right next to the dining hall. By making it very accessible, people are more willing to come for health care. We are there each morning and one afternoon a week.
When we began at Columbia Road in 1978, I was the only physician. In the next seven years, two other physicians came to join us; the three of us rotated between each of the three health services. Columbia Road also got another three-quarter-time physician and two full-time pediatricians—one received no salary at all, and the other was paid a very low salary.
The holistic model of health care calls for a pastoral counselor, physician, and nurse to be part of the team. We found that we also needed a social worker because so many of the people who come to us have such tremendous needs that impact upon their health. We soon found that it wasn't possible to practice without social workers.
I think of the gentleman who came that was hypertensive and whom I had been seeing for several weeks. As I talked with him, he began sharing that there were 11 people living in his apartment in the dead of winter, and the heat had been turned off. They had a baby in the apartment, so they turned on the oven and were trying to keep the baby close enough to keep him warm, but they were fearful of that. And here I was treating the hypertension with pills. The social worker was able to intervene as an advocate in terms of the housing situation he was living in. Social workers play a very significant part in what we do at all three places.
The next step for us is Christ House, which is right down the street from Columbia Road. That came about by our seeing a growing number of homeless patients and others who came in initially with a minor problem. Some just came in with a cold and were treated and sent out.
But here in Washington, as in many places, the shelters are only open at night. So they arrive at the shelter in the evening, but they are back out the next morning, walking the streets. They may have come in with a cold, but a week later they were back with pneumonia because they had been out in all sorts of weather.
Or maybe they came in, as many of the men especially do, with feet ulcerations from being on their feet for a number of years. They came in with ulcerations and while we were trying to treat that, they were walking around on their feet getting wet and sometimes frostbitten. We were seeing these ulcers enlarge and enlarge and enlarge until the patients finally ended up with an amputation. So we felt like we could no longer continue to send people who were sick back out on the streets.
We knew we wanted a building where people could come and live with us for short periods of time while they were ill. We shared that dream with Gordon Cosby, pastor of Church of the Saviour, and he made contact with someone who gave the money to find and renovate a building. We decided on the one across the street. We will live there with our families and other persons who are involved with the care of the 40 homeless people who will live there.
In 1980 Judi Floyd, a nurse here who is also part of Sojourners Community, and I walked down to the building that would later be Christ House. It was boarded up then. Judi and I stood in front of that building in silence and then she said, "God is claiming this building." We didn't have any money then to even think about buying such a building. And even when the money was given to us, we didn't know which building we would use. Another group was involved with the building, so it didn't look like it was a possibility. Then we got a phone call saying that it was available.
How did your family respond to the plan for Christ House?
My husband, Al, and I have three children. The oldest boy is 17, the other boy is 15, and we have an 11-year-old girl. We moved to Washington in 1978, and that was a very significant move for us. It was a decision we struggled with then, and intermittently struggle with now, in terms of the children.
But we really have had a sense that it probably was as much, if not more so, for the children's sake that we moved as for ourselves. There are times when we wonder whether we have discerned correctly, particularly when either of the boys has trouble here on the streets, which has happened occasionally. They become angry when something like that happens.
For two years before we moved into Washington, we lived outside of the city in a beautiful, planned community. My children thought they were in heaven. Every village in that community is built around a school, a swimming pool, and any recreation that a child could ever want. But my sense was, and I don't know the truth of this yet, that we were losing them in terms of values. I almost found myself running to the city.
They were not seeing the truth that we were learning working at Columbia Road. I wanted them to know the people I was with every day, not just the people I work with, but the people that are part of my life as patients and who are more like family than patients. I wanted them to know the struggles that people have every day and all the pain that so many experience. More significantly, I wanted them to be a part of the church community, not just coming in at set times for various events, but really sensing the community in a more in-depth way.
Could you tell us about your own journey from a successful suburban setting to where you are now?
I grew up attending a large downtown Methodist church in Indiana. I was always very active and involved in the church. At an early age I sensed the highest calling in the Protestant church was to become a foreign medical missionary. I sensed I should be a physician, but I didn't share that with anyone, and I was very unlikely to be a physician. The few contacts I had had with minor types of illnesses just scared me to death.
Later I decided to take a pre-med course, and I asked God to show me if that was the right thing to do. I continued on and had the sense that this was what I should do. At that time I was working toward overseas mission. I never knew that there were health needs here in the United States. I knew that there was some missionary work among American Indians, but I didn't have any sense of how blacks suffer in this country.
When I was in medical school, I had the opportunity to go to Zaire when the Belgians were pulling out and that country needed physicians. The World Council of Churches had set up the program, and one of my professors made arrangements for me to go. That was an important part of my journey, in terms of my own faith and of Jesus coming alive for me. When I left there, I still fully intended to go back overseas.
After Al and I were married, we were waiting for a visa to go to Pakistan. We sat for about a year after giving up our jobs thinking that we would be going overseas. It was a time of real discerning for us. We went to a Faith at Work conference and quite by happenstance met Mary Cosby, Gordon's wife. Her mother's family name was Goetcheus, so when she saw my name tag, she started a conversation. She invited us to come for a weekend visit. We visited some of the Jubilee buildings, part of the housing ministry of Church of the Saviour, and saw the decay before their renovation. Knowing that I was a physician, a group of people shared about the neighborhood in terms of health care. We went home with a real sense that this was where we were to come. We also wanted to be involved in a community.
The Pakistan visa did not come, but the opportunity to go to Indonesia did. It seemed like the perfect thing, but we had this nagging feeling that we were to wait. It was a hard thing to explain to family and to the Methodist Board of Missions. We eventually decided to come instead to Washington, uncertain about what would happen. We have found the Church of the Saviour community to be one in which people are encouraged to dream, to hear what God is saying to them, and then be supportive of those dreams.
You have written articles about serving Christ through serving the poor. Could you explain how your theology connects with your work?
I have really begun to experience how much God cares for the poor as I am among the poor. I find myself often struggling with whether Christians have the option not to become poor themselves, to become voluntarily poor. I think I experienced that in terms of being with people who hurt so badly and who are denied so many things. If I am to take on that burden, how can I live apart from it? I am just learning the truth of that.
I'm learning too that so much of what I do here, and have been doing here, is for the poor, rather than with the poor. I long to learn how just to be with the poor. I sometimes feel that the doing part keeps us from the being part, and that the most significant thing we can do is just be together in solidarity, sharing the pain. Out of that pain we can then begin to speak out together. I'm not sure that it's optional to do otherwise. That's part of my journey and part of my hope for Christ House, that as we live in a more intimate way with the people who will come to stay with us, I will learn that a little more.
I have a real sense of being given a great deal just by being with those who are poor. The poor have a deep sense of God's love and a deep sense of sharing faith even in the midst of tremendous suffering. They feel that God is with them. I think he is, too.
Could you say what you have learned about health care for the poor in this city and across the country?
Many poor people have no possibility of ever getting health insurance, so their health care has been primarily through hospital emergency rooms or outpatient settings. That means they will have long waits in specialty clinics. They go from clinic to clinic, and no one coordinates their health care.
We had a young schizophrenic homeless woman here in the area. She had a large uterine mass, and it took us weeks to build enough trust with her so she would even consider having a gynecological evaluation. One of our staff went along because she was still very agitated. They got to the gynecology clinic at 12:30 p.m. and at 4:15 the nurse came out and said that the doctor needed to leave and they would have to reschedule her. When the staff person told the nurse how difficult it had been just to get her there, they went ahead to see her, but they wouldn't let the staff person into the room. When they started to examine her, she asked for the staff person to come in. The physician, a resident working the rotation through the clinic, wouldn't allow that. He got angry and walked out.
Another problem with emergency rooms and clinics is that the patient sees a different medical student or resident each visit. They are asked the same questions that they were asked the time before.
When we were first starting at Columbia Road, a teenager came into the office for care. As she was leaving, she asked how I could be her doctor. I said, "Just by your wanting me to be." She said, "You mean I can tell people that I have a private doctor?"
Most of the poor never have the opportunity to have a long-term relationship with a health care provider, be it a physician or nurse practitioner or midwife. That's one of the reasons the infant mortality rate in Washington is one of the highest in the country. Most of the Medicaid women have to go into hospital clinics where they are seen by a different doctor every time they go back during their pregnancy. They feel like no one listens to them. They are given vitamins and iron and they are sent right back out.
We had a woman come in who had had surgery 10 years before for cancer and had a suspicious-looking area. Because her public clinic bills were running $25 a visit, she came to us. But all her records from past care were at the public clinic, so we sent her back there with a letter from us. A medical student saw her and said she just had vaginitis. She came back in, we checked her again, and got money to send her to a private gynecologist. She had a biopsy done, and it was cancer. She died several months after that.
The poor absolutely get lost in this system of health care. It is so dehumanizing that they just don't go. They end up in an emergency room and are treated for some crisis and sent right back out. The next time they get any health care, it is back in the emergency room again. Basic health needs among the poor here in the United States are not being met, and the result is a much more expensive form of medicine.
It's hard to prove that because you treated someone's high blood pressure, you prevented them from having a stroke or an early heart attack. But that probably is true. It is much more expensive to provide care for someone who has had that stroke, who ends up in a long-term nursing setting, than it would be to offer basic health care and education. But it is hard to convince those in health planning within the government that it is not just more humane to provide continuity of care and good basic health care, but that it would also be cost-effective. Some of those who, when we look to different models, might be most opposed are those in the large medical schools that train physicians and are dependent upon the poor not having any place else to go.
What is the current situation in terms of government support for the medical needs of poor people?
I have heard that 38 million people here in the United States have no health insurance, and it's a growing number of people. It's a myth that anyone who is really poor can get Medicaid. Most of the people that we've seen are ineligible for any kind of care. Eligibility requirements have become stiffer and stiffer.
We have all the statistics to show what this lack of health care means for minorities. In Washington the cancer mortality rate for black males is 60 percent higher than for white males. Anything you look at—be it infant mortality, or any of the infectious diseases, or cancer—is much higher among minorities than it is among whites because the minorities don't have financial access to care.
The general feeling in much of society is that physicians are compassionate people. But it is clear from what you're saying that a great disparity exists between what you are trying to do and the approach of most other physicians.
I think physicians, by and large, are compassionate. My sense is that they lack contact with the poor; they don't realize what it means to be poor and what it means for a person to have to go into that out-patient clinic. I have heard that here in Washington less than 20 percent of the physicians accept Medicaid patients.
On paper, Washington has many residents in training and large universities that are well known and highly respected, so people think we've got the best health care possible. But they don't realize what's happening to the poor people. And it's not just physicians. I find that when I talk with people in suburban churches. I sound like I am talking about some foreign country or like I am making stuff up. It's not because people aren't compassionate, it's because they lack contact with the poor who suffer.
Could you explain how what Columbia Road is doing is an alternative to the current system? When you envision a health care system for the poor, what do you see?
There are two approaches to the problem. One is to give the poor the financial access to enter the private health care setting where they could have continuity of care. The other is to change that dehumanizing public system so that instead of long waits and varying doctors, there is someone involved that the patient knows well and can ask questions of to assume a sense of responsibility for their own health.
The models that have worked include a community-based primary health care center that is also a social center for the neighborhood. The emphasis is on community, continuity of care, and preventive medicine.
My sense is that the church needs to take a wider role in health care for the poor. I don't think the government is going to do it. I don't think the church can do everything but it needs to get involved.
Back in '75, when we were trying to figure out where we were to be, I went to talk with those who were involved in our own denomination and knew the national health scene. I asked if there were any churches involved in health care for the poor and they said no. I think a growing number of medical students sense a real call to be with the poor, but they need the church to support them. Just in the first seven years we were here, four students have gone back and picked up pre-med courses and are in medical school now. They all want to be in church-based health services for the underserved. As churches reach out to the poor, God can dream dreams through them to reach out to more poor people.
I am glad to see the church put emphasis on holistic health care, and I wouldn't want to practice in any other model. But I get worried when I see the energy going so much toward the model of holistic health care that they forget about the poor. My sense is the church doesn't have the option right now to do that because there are too many people whose basic health care needs are not being met. The church needs to hear the suffering of people and use the model as a means of outreach to the poor.
What do you think it will be like living at Christ House after working all day amidst so much suffering, and then going home to more? Where do you get hope, given that the situation is getting worse rather than better?
I am now part of a mission group of Church of the Saviour, made up of the physicians here. We're together each Sunday night for dinner and a time of study and worship. I have a real sense of support from that group.
Living at Christ House will be my first experience of living in a setting like that. It will be for all of us. None of us have ever even lived together in the same building. So I am talking more about what I envision than what I know. I really look forward to living together with the poor on a daily basis. I look forward to sitting in that dining room over there and eating together and sharing together as a family. My sense is that it is obedience. I know it's obedience for me; is it also obedience beyond that? Is that what the gospel is about? I'm still learning that.
I don't think this will be where burnout comes for me. Every day we will have times of prayer together, structuring our lives so that prayer is an important part of what we are doing. Right now I really look forward to that. We have a deep sense of obedience in all of this. We don't see it as hopeless.
I heard Daniel Berrigan speak a couple of years ago. During the question and answer session, someone said, "Don't you realize that the end of the world is coming and that all you're doing is putting on a Band-Aid?" Berrigan said he couldn't agree with the gentleman more, but why didn't he come along and put a second Band-Aid on?
When a person comes to me with so many needs and I can't intervene in terms of the need for a job and housing, at least I can care when the person is with me. I offer the few gifts that I can share at that point. That is a gift for me, just to be able to be with the person. There is a real sense that God is dreaming through us to care for the poor whom he cares for so deeply. We have been here to express that caring. And many things have happened that have been much beyond anything that has occurred because of us.
Do you have any success stories to share?
One young mother lives in a terrible, rat-infested apartment building with a lot of drug dealing right outside the door. Her two children are now incarcerated because of drug-dealing activities.
When we first met her, she was severely alcoholic. She had been coming in periodically, but she would not get any help. Then about a year ago, she came in very ill, very jaundiced and anemic, and her liver essentially had failed. She had developed what is called alcoholic hepatitis. She had no insurance, but one of the hospitals let us admit her.
She now comes regularly for counseling, has a sense of her own worth, and is not drinking. The two boys are still in jail, but throughout all of this she has had a real sense of God. She talks about how the Lord has been with her.
Do most of your patients return for ongoing care?
We have a lot more than I would have anticipated, especially among the homeless. It's usually assumed that the physician or health service shouldn't call people up, that people ought to be responsible for their own health, and if they don't come in they have made that choice. But we do a lot of follow-up. If they are homeless, we get word out to the shelters.
How do you keep going financially at Columbia Road?
When we first started out, we thought that the health service would be financially viable so we'd be able to apply for foundation funds. We are all working at low salaries, and we have a sliding fee scale. Well that idea certainly changed, and in many ways we are grateful because we are seeing poorer and poorer patients. But it also means that we are having to do more fund raising.
In 1985, we had to raise $300,000 a year just for Columbia Road, because patient fees cover only 40 percent of the budget. We estimate that it will cost us $500,000 a year for Christ House—and that's all through private donations.
We struggle constantly. We don't have money for our next two pay periods. We have faced that several times in the past. Our experience has been that we have to be obedient and faithful to the dream and then work at the money afterwards.
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