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In 1995, HCH's largest source of money, the National Health Care for the Homeless Council, yanked its financial support, citing poor management practices. The coalition scrambled to pick up the slack. Comic Relief funds were awarded to Grace Hill, which was already receiving a $1 million federal homeless-health-care grant. Grace Hill used some of the funds to provide four full-time nurses to work at 32 homeless shelters in the metro area. At this time, Grace Hill also decided to bring the HCH advisory board under its wing.
After his residency, Rottnek wasted no time putting distance between himself and the world of corporate medicine. Putting profits before patients chafed his belief that medicine was a sacred mission. With his new physician's shingle, he stepped in to help rescue Harbor Light and turn it into a weekly clinic. To pay the bills, he worked at Family Medicine Institute, a nonprofit that provides general-medicine care to the poor of St. Louis County.
Spare time was slim and slight. Rottnek gave what little there was to volunteer work at places such as Harbor Light. Still, this healer and activist was not content.
"Any time you are working within a system, that is not going to be ideal, because we are not an ideal world and we are not a perfect people," he says. "But I don't think settling for the status quo is any way to do a job, especially when you are dealing with people's lives and when you are not providing the best possible care, for whatever reason."
And Rottnek didn't think his patients at Harbor Light were getting the best care possible from Grace Hill. The nonprofit operated a small dispensary at the shelter and provided some clinical support on the Tuesday evenings the Harbor Light clinic was open.
He sent his patients to Grace Hill for lab tests but didn't get back the results. He wrote prescriptions for homeless patients that Grace Hill didn't fill. Grace Hill told Rottnek the homeless-health-care grant was drained by unexpected costs. As a result, the agency couldn't help with basic supplies for the clinic -- such as a rinseless antiseptic hand soap Rottnek had to buy with his own money because Harbor Light had no sinks.
Rottnek suspected the homeless were taking a back seat to other obligations, other bureaucratic imperatives.
"Grace Hill has some very good programs that they run out of the neighborhood health centers." he says. "The problem is that the people have to get to those health centers, which can be difficult. They do a good work in the community. I am not disputing that at all. I just thought they could do better in regard to the homeless."
When Rottnek was voted in as president of the Health Care for the Homeless Coalition, the advisory board Grace Hill had brought into its fold, he saw an opportunity to voice his concerns.
But he never anticipated how prickly things would get. Or how fast they would get that way.
For several years, the HCH advisory board hummed along nicely.
"We had a lot of good people on board," Appoo says. "The meetings were nice, and we did a lot of sharing."
Ideas and nice meetings weren't the only thing shared by board members.
Grace Hill held the strings on federal funds for homeless-health-care programs, deciding who would get the money and who wouldn't. Most members of the HCH board worked for agencies getting money from Grace Hill.
"Too many providers were on the board," says Laura Drake, a former board member. "It was somewhat of a conflict of interest."
By Appoo's own admission, the board was passive. But when Barbara Weakley, director of mental-health programs at St. Patrick's Center, a homeless shelter, stepped down as board president and Rottnek was voted in, those nice meetings became contentious affairs.
And the sharing centered on hard words and mistrust.
Rottnek brought Sandra Duvic onto the board. Duvic, a seasoned, no-nonsense administrator at the Institute for Research and Education in Family Medicine, where Rottnek still works, became board treasurer. Another ally with ties to the institute was Drake, who was elected vice president of the board.
"When those three came on board, the meetings, which used to be so good, turned contentious," Appoo says. "Three people from one organization were creating a very negative atmosphere, and all of them were from Family Institute."
Duvic says she was simply asking questions about how money was being spent. She demanded clear answers on the number of homeless patients served by Harbor Light and other agencies.
"I couldn't understand that if the clinic at Harbor Light was carrying the lion's share of providing care to the homeless, how come the funding didn't reflect that," Duvic says. "It only makes sense that if one site had an increase in patients, the funds should be shifted to better meet that need.... The numbers never added up. We kept asking for the same things, and they would always bring something in but never what we asked for."
Appoo cringes when Duvic's name is mentioned.
"I was so glad not to have anything more to do with her," she says with a roll of her eyes.