WASHINGTON – When Dr. David Gregory worked to open a health clinic for the uninsured in 1991, he thought that he would be treating residents of the nearby housing projects. Most of the residents were African Americans.

Since then, however, Siloam Clinic has become the treatment center of choice for a large population of refugees and immigrants from some 100 countries, ranging from Afghanistan to Vietnam.

“Things changed–TennCare [Tennessee's Medicaid program] expanded to include more uninsured patients, and the patients didn't need us so much,” said Dr. Gregory, who is with the division of infectious disease at Vanderbilt University in Nashville, Tenn.

“But one morning, in walked a Vietnamese man. He had spent 9 years as a prisoner of war, and survived torture and forced labor,” he said. “I started looking after him and his wife. It turns out that there were about 4,000 Vietnamese refugees in the area.”

Before Dr. Gregory knew it, word spread among that refugee community that care was available at Siloam at a nominal charge–and the clinic had many new Vietnamese patients.

Now, 80% or so of Siloam's patients are from Nashville's expanding refugee and immigrant population, he said. The clinic's scope of practice includes health screenings, immunizations, primary care, patient education, and specialty care. The clinic receives funding from Medicaid, federal grants, donations, foundations, private insurance, and patient fees.

“Establishing trust [with these individuals and their communities] is dependent on integrity and honesty,” Dr. Gregory said.

A faith-based endeavor that takes its name from biblical references to the Pool of Siloam, the clinic has grown from its humble beginnings in a renovated apartment to a new, debt-free, 12,000-square-foot building that includes 12 examination rooms and a chapel.

The need for this type of community service has grown dramatically since 1991 as the population of uninsured and underinsured grows, Dr. Gregory said. He offered some advice for physicians who, seeing a need in their own communities, want to help.

“What's a doctor to do in the face of these daunting challenges?” he asked. “You can do something, but it takes planning. There are many land mines.”

The first thing Dr. Gregory suggested for those physicians who believe they may want to open a similar clinic is to examine motivation.

“Why are you doing it? Is it altruism? Faith-based? An intellectual challenge? Be honest about why you want to be involved,” he said.

Next, he advised, “do not go alone. If you start talking about it, you'll find people who share this passion.” Then, assemble a board and delegate tasks.

Money obviously is important. “Probably the biggest mistake we made at Siloam was being undercapitalized at the very beginning.” The clinic started with an annual budget of $30,000, he said. In addition, depending entirely or almost entirely on volunteers can be chancy, because volunteers don't always show up to work, he said. Therefore, a clinic of this type should hire paid staff.

At Siloam, patients are expected to pay something. “We're not a free clinic,” Dr. Gregory pointed out. “Patients make a $5 donation. The rationale was to encourage some sense of participation and avoid a sense of this being charity,” Dr. Gregory said. The clinic also asks for patients to pay half the cost of routine lab test fees–for example, a routine complete blood count costs $3.00, so patients pay $1.50, he said, adding, “we get very good wholesale lab prices.”

However, obtaining images and other diagnostic tests has proven more challenging, although Siloam has some testing donated each month, Dr. Gregory said. And to cover patient hospitalizations, the clinic approached Vanderbilt Hospital, which agreed to provide 12 hospitalizations each year; the first year, it cost the hospital $300,000, Dr. Gregory said, but “it keeps the patients out of the emergency room.”

And of course, it's the patients who make all the planning and strategizing worthwhile, he said.

Dr. Gregory spoke of a patient, Abraham, a 25-year-old Sudanese refugee who presented with a week-long history of fever, headache, nausea, vomiting, and weakness. Abraham–a Tennessee resident for 4 years–recently had returned from a 1-month stay in Uganda, where he had been searching for family members.

A physical exam showed a temperature of 102 degrees, no jaundice, but a palpable spleen tip. Dr. Gregory said he started Abraham on mefloquin and confirmed his malaria diagnosis through a peripheral smear that showed falciparum malaria.

One week after treatment for malaria, Abraham felt well but had been fired from his job at a poultry packing company because he was late returning from his Uganda trip, and then was sick for 7 days, Dr. Gregory said. The young man subsequently found a better job.

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Dr. David Gregory says his health clinic for the uninsured is now debt free. Joicelyn Gregory

Nashville Clinic Focuses On Immigrant Groups