Where do we go from here? Five thoughts on Portland’s new budget

It’s been hard to get a clear report on what the new budget that the Portland City Council passed last week actually means for the India Street clinic and the city at large.  Here are five thoughts about where things are at, how we got here and what we can do about it.

1.  While the India Street clinic will stay open, in a move that was both unnecessary and cruel, the City Council decided to close Positive Health, the highly successful, much beloved HIV program that the municipality operates there.

Like many Portlanders, I didn’t really know very much about the Positive Health program until I started following this story about a month ago.  But as I’ve met more and more people in our community who have struggled with HIV, it’s become clear.  For more than a decade, Positive Health has been a godsend.

At the first major public hearing on the budget, one man who had been a patient there shared about how, as a gay man who had faced more than his share of alienation over the course of his life, walking into Positive Health always felt like coming home.  When his mom passed away, the entire staff of the clinic even signed a condolence card for him.

Positive Health has the numbers to show for it.  95% of patients who enter the program stop showing symptoms of HIV within a matter of months, having achieved what medical professionals refer to as full “viral load suppression.”  In comparison, most healthcare facilities have suppression rates closer to 60%.

Positive Health is now set to shut down within the year.

This sucks.

In its place, a local independent nonprofit service provider, Portland Community Health Center (PCHC), has begun the process of creating their own HIV program capable of securing the federal “Ryan White” funding that currently fuels Positive Health.

While the City will play an active role in guiding the creation of this new program, naming a few citizens to the transition task force and reviewing regular reports as PCHC establishes the new program, ultimately, the new program will be under the jurisdiction of PCHC, a private entity, not the community at large.

This new program simply won’t be an adequate replacement for Positive Health.

PCHC, like any “federally qualified health center” (FQHC), is focused largely on providing “primary” care.”  The idea is that every person, no matter how much money they make or where they come from, should have a personal relationship with a doctor whom they can visit regularly for check-ups.

But primary care, while essential, isn’t really a substitute for the level of expertise and focused attention that a program like Positive Health is able to provide.

While it remains to be seen what the new PCHC program will look like, when Leslie Clark, the Executive Director of PCHC was asked by the Portland City Council to describe her vision, she described using the new funds to bring in a few more part-time specialists, perhaps from a local hospital, to advise at one of PCHC’s primary care clinics.

It’s good to know that there will soon be more experts on hand to assist PCHC’s HIV Positive patients, but a program with a few doctors coming in to help out for an afternoon or two a week won’t really be equivalent to Positive Health, which had its own designated lab and highly competent medical staff.

As the quality of care suffers, the viral load suppression rate seems likely to drop as well.  At present, there are around 220 patients at Positive Health.  With 95% viral suppression under the current program, it stands to reason that 209 of them may soon be okay.

At PCHC, who knows?  Will the patients’ appointments be farther apart?  Will the less experienced, less focused staff miss things?  Does this mean we lose twenty of those people instead of eleven?  Forty?  At the average healthcare facility, with a 60% suppression rate, 88 of these 220 people would never recover.

This sucks.

The City Council’s stated reason for cutting the municipal program is that the Ryan White grant is increasingly being targeted toward FQHCs, not municipalities, especially those nonprofits with the latest electronic medical record keeping infrastructure.  Given that PCHC has the right computer system and funding designation, they argue, the services need to move over there if they are to continue.

Except they don’t.  At least not immediately.  Not like this.

At the national level, the Ryan White program is divided into funding “districts,” and Positive Health is currently the only eligible candidate in Southern Maine.  The money set aside for our district has got to go somebody, and nobody else was about to compete for it.  It seems highly unlikely that we would have lost it.

And the new computer system, far from being impossibly burdensome, could have been purchased like any other routine capital investment.  As the new record keeping standards have come out, every clinic in the country, both public and private, has had to invest additional money into keeping their infrastructure compliant.  Portland should have done the same.

That said, is it possible that, over time, there could have been a good way for Positive Health to come under the PCHC umbrella?  I honestly don’t know.  It’s not my area of expertise.  But that isn’t what happened here.

This isn’t a merger.  It’s not an acquisition.  It’s a death sentence.  The Portland City Council has decided to destroy Positive Health, a wildly successfully program that meant the world to thousands of Portland residents, and replace it with something far inferior.

More should have been done to protect Positive Health, and it’s a serious dereliction of duty that the City Council chose to kill it like this.  Personally, I have a hard time seeing their decision as anything but reckless and cruel abandonment of an incredibly vulnerable population.

2.  India Street as a whole took a significant hit.

One of the more confusing headlines coming out of the vote has been that, as unfortunate as it is that the India Street clinic will no longer be serving the 220 patients who were at Positive Health, the clinic’s remaining 2,600 patients have all been “saved.”  All the other programs, we’re being told, have been left fully intact.

This is misleading.

Today, if a local person wants to make sure they don’t have a venereal disease, they can come into India Street and meet with a friendly social worker from the STD program who will ask them some basic private questions and collect test samples.

But that social worker won’t actually analyze those samples.  A medical professional does that.  And, as things stand currently, the medical professionals who do those tests work for Positive Health, and they perform those tests on equipment that belongs to Positive Health.

In fact, neither the Needle Exchange nor the drop-in STD testing program employ any doctors or nurses.  Both programs only employ social workers. They rely on Positive Health to meet their medical needs.

Closing Positive Health, therefore, won’t only impact the clinic’s HIV patients, it will impact everybody at the STD program and the Needle Exchange as well.

When I spoke with somebody from the STD program at the vote on Monday, she was scared, unsure of who would conduct her program’s STD tests after Positive Health closes.  Most likely, I’d imagine, the clinic will send the tests to a lab outside of the building, making what was once a quick proposition into something that takes much longer and will probably cost the City of Portland substantially more money to carry out.

My sense is that the borders around the three programs were never very well defined.  Positive Health employed two full-time people and two part-time people, all of whom were always on hand to share resources, answer questions, conduct tests and do whatever else they could to help the folks at the other programs.

Make no mistake, even if the lease is renewed at 103 India Street and the lights stay on and the doors stay open, when the people working at Positive Health lose their jobs at the end of the year, everything happening at the clinic will be affected.

3.  There was an incredible outpouring of resistance from the community in solidarity with those who will suffer the most.

As tensions rose around the proposed closures, thousands of people from throughout Portland got involved in speaking out.  There were several rallies, including a big march on May Day, two official press conferences, an online petition drive that received thousands of signatures and countless Facebook posts.

Most importantly, a legion of people from the community came out to pack City Hall on both the day that the budget was first discussed by the City Council, and again two weeks later, when the budget was ultimately voted on.  We saw ministers and doctors, social workers and neighbors, patients and their advocates, all coming out to speak in favor of protecting the clinic.

Left to their own devices, humans are usually pretty chaotic, especially in a city.  Between work and family and friends and hobbies, each of us is pulled in a million different directions.  These days, it can be hard to find somebody who even watches the same TV shows as you.

Out of all of this mayhem, we saw a slew of genuine community organizers step up to bring this jumble into order, unifying folks across the city behind the simple common message, “Save India Street!”

This was true social movement.  We weren’t just moving through the day on our own, each of us walking around with our head down.  We were moving in unison.  Coming together.  Looking out for each other.  Looking up toward a brighter future for our entire community.

For a little while, everybody was moving in the same direction, trying to drag the often intractable monstrosity of our city government forward.

All of this effort still wasn’t enough, but it made an unquestionable impact.  The budget that the Finance Committee sent on to the floor of the City Council called for India Street to be completely shut down.  It’s only through the strength of our community outcry that so much was saved in the Council’s final vote.

In the end, it wasn’t a victory for the people of Portland.  It was a loss.  But the power that our team demonstrated was inspiring and new.  Our energy is fresh and growing, and this struggle is far from over.  On the tectonic level, at least, we got this.

4.  It became abundantly clear that the City of Portland’s decision making process is awful, disempowering and unaccountable.

Looked at from a certain angle, Council Chambers is a perverse distortion of a theater.  In the front is a stage where the Council sits.  In back is the community, assembled as an audience, sitting on both the main floor and a balcony.

The main event at a public hearing, the testimony, comes not from the front of the room, but from the back, with the speakers facing the reigning elected officials with their backs to their fellows.

This architecture is designed to compound feelings of disempowerment.  With this setup, summoning the courage to share your truth to your community, which is always a daunting undertaking, doesn’t feel like you’re rising in front of your peers to offer your perspective as an equal citizen.   It feels like you’re a peasant, kneeling before the king in his court, begging mercy from his wrath.

But no matter how rigged it clearly was, dozens of people were still willing to play the game that was in front of them, eager to do whatever they could to stand up for those in our community who are suffering.  From behind the rickety microphones, people cut open their hearts, spilling divine, painful words about their fears, their frustrations and their desperate hopes for the lives of those they loved.

Once the public comment was over, the theater reversed.  Now the Council, the only people in the room who had been able to see the faces of those testifying, had the floor.  Many community members left at that point, but a ton of us stayed, eager to see what would happen.

As the Council began discussing the show they had just seen, it became increasingly clear that we were not getting very good reviews.

Councilor David Brennerman found the testimony, both that night and in the preceding weeks, to be in rather poor taste.  Sure the municipality was cutting vital human services, but did the people of Portland really have to be so disrespectful of the Council’s authority?  He wished they would stop “behaving badly.”  After all, the councilors had been elected.

Councilor Jill Duson agreed.  She lauded her colleagues for coming to an agreement that “everyone could live with, no pun intended.”  Well, perhaps not all of the HIV positive patients could live with their services being cut, but certainly, at least most of them would live.

Councilor Spencer Thibodeau explained how excited he’d been to participate in his first budgeting process and finally see up close “how the sausage is made,” borrowing a rather offputting turn of phrase from the 19th century German Chancellor Otto Van Bismarck.

Although somewhat less bloody than the violent statecraft of unifying Prussia and Austria, Thibodeau’s probably right that the brutal work of closing the Positive Health program is somewhat akin to operating an abattoir.

At best, this system is broken.

The municipality would be a big ship for anybody to captain.  With a couple of notable exceptions, almost nobody on Council has worked as an educator or done anything substantial in the nonprofit sector.  Putting them in charge of both a school system that spends over a hundred million dollars a year and an equally substantial social service infrastructure seems foolish. And dangerous.

While the City does employ some great staff, Jon Jennings, the City Manager, has built his career as a real estate developer and co-owner of the Portland Red Claws.

How surprised can we really be when somebody like that turns out to be good at “streamlining” building permits, yet does nothing to further our community’s social justice needs?  As the old saying goes, when you’re a hammer, the whole world looks like a nail.

Local people need the power to participate in making these decisions.  Most of these councilors need to be voted out.  This whole decision-making process needs to be overhauled.

The only question is how.

5.  There is an international, multi-faceted movement under way that will soon dramatically transform things at City Hall. We need to be part of it.

On December 20, 1990, the first website in the world was launched by the computer scientist and inventor Tim Berners-Lee.

Over the next couple decades, however, even as the Internet was changing all of our lives in a plethora of ways, the taxi industry remained fairly unaffected.

Then in 2010, Uber came out.  Then Lyft launched in 2012.  Today, only a few years later, if you’re driving a cab or even just riding in one, you’re in a whole new world.

The hotel industry has a similar story.  Dating.  Real estate.  Entertainment.  Across the board, the story of the digital era is the story of things moving in punctuated equilibrium.  They evolve slowly, one innovation at a time, until BOOM!  Everything becomes completely different.

This kind of drastic sea change hasn’t happened yet in the world of municipal governance.  But I’m fairly certain that it will.

Portland is an incredible place surging with people of remarkable talent, experience and potential.  If we can shift the nature of power, I really believe that the capacity is there for us to build an incredibly healthy city.

Portland can become a place where information is transparent.  Where everybody truly gets to have a say in determining the future of our city.  Where diverse people work together to share resources responsibly.  Where we move forward intelligently as a community.

Municipalities are hell holes of bureaucracy, paper work and committee meetings.  They’re difficult institutions to change.

But City Hall is our house.

We elect the folks who sit at the front of the room.  We pay for everything out of our taxes, whether it’s our name on the bill or our landlord’s.  If we don’t like the decisions that are being made, and lately I certainly haven’t, then we can change what’s happening there.  Nobody’s going to send us to a gulag.

In the words of the great Joe Hill, “Don’t mourn.  Organize!”

Rob Korobkin

About Rob Korobkin

Rob is a software engineer, community organizer, teacher and musician. He can often be found at Peloton Labs, staring at his laptop, drafting diatribes and programming software late into the night.