On the sidewalk on Oakland’s International Boulevard, Marlen Valencia swayed softly from foot to foot as her 2-year-old daughter Sara slept on her shoulder. A stomachache that had lingered for the past month had made the little girl stop eating, and she was losing weight.
The 38-year-old Fremont mother waited for hours this Tuesday morning in May, standing and occasionally sitting at a spot marked with orange tape, keeping a 6-foot distance from two dozen others lined up with her, all desperate to see a doctor many of the region’s uninsured come to see.
A friend had suggested she try this clinic near the Fruitvale BART Station after her attempts to get an appointment using her Kaiser insurance failed. To see Dr. Carlos Ramírez at Terra Nova Medical Group, a storefront clinic sandwiched between a dulceria and a Mexican curiosity shop, patients need only pay an $80 flat fee.
Ramírez, 59, an Orinda resident, has been tending to patients like Valencia at his East Oakland office for nearly 10 years. Most of them are undocumented, Spanish-speaking and among the working poor. When his patients can’t afford his care, he often treats them for free. There are no appointments; it’s first come, first served. And in the time of the coronavirus, his practice has become an even more crucial source of health care for one of the most vulnerable communities in the Bay Area.
Latinos have disproportionally tested positive for the coronavirus in the Bay Area’s three largest counties. In Alameda County as of Tuesday, 40% of cases where the race of the person is known have been Latinos, compared with 22% of the population.
With many other small, cheap clinics having closed during the pandemic, Ramírez is now seeing patients from as far away as Eureka, people seeking care that is often put off because they can’t afford routine visits. He can’t test for the coronavirus, but screens patients, and has written more than 40 letters to help those who exhibit symptoms get free testing. He also writes letters for patients who want to return to work but need a doctor’s note confirming that they do not show symptoms of the virus.
“We’re one of the only clinics able to provide face-to-face services,” Ramírez said. “We’re there on the front lines of the battle.”
The tiny clinic’s proximity to the pandemic, though, has made the doctor and his staff anxious. Terra Nova, which once stayed open late and sometimes on weekends, now holds regular hours only on Monday through Wednesday, allowing time for a weekly deep cleaning of the office and reducing the staff’s exposure.
But, as Ramírez continues to treat this community of roofers, restaurant workers and day laborers, he is juggling another existential battle, one that threatens his future. Last year, the Medical Board of California filed a complaint against him alleging he had overprescribed pain medications to three patients. His case before the board is nearing, and he’s worried about the fate of his practice and his patients.
In a proposed settlement, the state board has recommended a punishment that could shut down his clinic. One doctor who reviewed the board’s allegations cited numerous “red flags” and said the proposed sanction is “one step below an outright pulling of his license.”
Ramírez and his attorneys say the board is overreaching. They say his paperwork may have been inadequate, but he was not negligent, and his clinic dealt with unique challenges that come with treating indigent patients. The medical board will not comment on his case until it is resolved.
“This review is pretty much hanging me,” Ramírez said. “They don’t understand the practice I have. There are a lot of limitations. We’re dealing with the poor and underserved people. It looks like they want to make me into an example.”
Once inside the Terra Nova lobby, a high-ceilinged space splashed in bright yellow paint, Valencia and daughter Sara were greeted by a framed poster of artist Frida Kahlo above the reception desk.
The clinic door was propped open to increase ventilation. Two men waiting their turns sat apart in the lobby, their forlorn faces partially hidden by surgical masks. One of the doctor’s five rotating medical assistants took the little girl’s temperature and weight, then quickly escorted them into one of three exam rooms to see the doctor.
Even with a face shield and two masks covering most of his face, Ramírez comes across as affable and approachable. His wavy gray hair pops out from his protective gear. He uses jokes and small talk to put suspicious or nervous patients at ease, establishing a back-and-forth that can sometimes stretch an exam to an hour or longer.
As Sara wailed and squirmed in her mother’s arms, Ramírez probed her ears, throat and abdomen. The girl has some sort of gastrointestinal infection, he explained. He prescribed antibiotics and, speaking Spanish, advised Valencia to give the girl lots of fluids, Pedialyte and to avoid milk.
Outside the clinic, Ramírez’s wife, Carla Furtado, who works as the office’s director of business, walked the line of waiting patients with a clipboard, gauging the urgency of their conditions and screening them for possible coronavirus symptoms. Just a half hour after the clinic doors opened, Furtado’s clipboard with 26 openings for the day was already filled.
Having secured his visit with Ramírez, Domingo Pelayo waited patiently outside a shuttered National Dollar store nearby, sitting in a folding chair next to his wife. The 83-year-old has gout, and his feet, hands and face are swollen.
Pelayo lives in Michoacán, Mexico. He was visiting his children on a visa, but the pandemic shut down most air travel, so he found himself stuck in the U.S. and out of medication. He’s gone to Ramírez’s office over the past four years, whenever he visits his family in Oakland.
“I have faith in him,” he said through an interpreter. “Other doctors charge a lot of money.”
Lately, many of his patients are residents of El Salvador, Guatemala and other Central American countries, Ramírez said, people visiting when the pandemic hit and left stranded. Like Pelayo, many suffer from chronic conditions — diabetes, heart problems or prostate issues — and are in need of medications.
Other regular patients here are undocumented workers, many of them in jobs deemed essential during the pandemic.
In 2018, California had an estimated 1.2 million undocumented essential workers. Overall, foreign-born California residents that year made up more than a third of the state’s essential workforce, according to a Center for Migration Studies report released earlier this month.
“Undocumented individuals are among those who have no safety net for health care and are excluded altogether from many vital services,” said Sarah Dar, director of health and public benefits policy with the California Immigrant Policy Center. “Undocumented immigrants are overrepresented among various sectors of the economy deemed ‘essential’ and cannot stay home; thus they are risking exposure to keep our economy running.”
While there are government-funded clinics in operation in the Bay Area, other low-cost facilities have closed during the pandemic because they simply don’t have the infrastructure to operate, said Alvaro Fuentes, executive director of the Community Clinic Consortium in Contra Costa County. The other option is a hospital emergency room, but that is primarily for life-threatening emergencies.
And Fuentes worries about funding going forward: “We’re bracing ourselves.”
In a screening chair in the clinic, Juan Perez, a 50-year-old Antioch resident, sat with a finger probe checking the oxygenation level of his blood. His was low, only 94%, which got the attention of Ramírez’s staff. After leading him into an exam room, Furtado flipped a card posted outside the door from white to yellow, signaling a possible coronavirus patient.
Perez, who is diabetic and uninsured, explained that eased sheltering restrictions have allowed him to resume work laying carpet with three co-workers. He had a sore throat and felt sick, he said, and was taking medication for his asthma and seasonal allergies. He had no cough.
Ramírez sent him home with a letter to help him get tested for coronavirus at a free Contra Costa County facility.
Seated in another exam room, Carmen Armenta, a 30-year-old medical assistant from Hayward, said she chose to visit Ramírez rather than go to Kaiser, where she has insurance, because he takes time to listen to her when she sees him. It’s a common complaint among Ramírez’s patients. At big hospitals, they say, they are often offered only phone consults or physical therapy instruction through an online video.
And Armenta sees Ramírez as something more. “For me, he’s like a mentor,” Armenta said. “Aside from taking care of me healthwise, he motivates me. He’s a minority himself and he’s achieved a lot.”
Ramírez’s story of how he came to be a storefront physician is poignant. He grew up poor, he said, in a family of 10 children in the small town of Colima in southwestern Mexico. When he was a boy, his oldest brother died of pneumonia.
“From there I had a goal of studying hard,” Ramírez said. “I became a doctor when my oldest brother died.”
His father joined the U.S.-Mexico bracero program in the 1950s and ’60s, allowing him to work seasonally picking cotton in the Imperial Valley. Back home, Ramírez said, he would work construction with his father, loading trucks, mixing concrete or carrying bricks — “whatever we could do to survive.”
At the University of Colima, he was the first in his family to go to college. He would go on to medical school there, always returning home over summers to work construction.
In 1990, Ramírez emigrated north. He met Furtado, who grew up in Berkeley, at UC Irvine during a World AIDS Day conference. After working in Southern California for several years, the pair married in 1995, then moved to the Bay Area two years later.
He opened Terra Nova Medical Group in 2010, turning a former Oakland photo lab into his dream clinic.
“I was motivated by seeing the uninsured and the lack of medical services … how unaffordable it is and people not having access,” he said. “You know it’s a passion to help these folks, hardworking people, who don’t have money for resources.”
Before the pandemic forced him to limit the clinic’s hours, it would be open Saturdays, some Sundays and late on weekdays to fit his patients’ work schedules. His clients ranged from those with diabetes or heart problems to victims of street robberies.
“A lot of them have been treating themselves before they come,” he said.
Often, patients show up with just enough money to pay for their visit and can’t afford further treatments or lab work. Ramírez works with low-cost medical providers, but often, he said, further care goes undone.
In May 2012, a man visited Ramírez’s clinic. He told him his regular doctor was out of town and he needed help with anxiety, weight gain, lower back pain and gout. Ramírez prescribed 30 tablets of the narcotic Vicodin and 90 pills of phentermine, an appetite suppresant, but did not perform a back or neurological exam, according to a Medical Board of California complaint filed against Ramírez last May.
The state board alleges that this man, “Patient A,” visited Ramírez about 20 times over a six-year period for numerous ailments. During three of those years, Ramírez allegedly prescribed the man 600 tablets of the sedative Ambien, 940 pills of the narcotic Norco and 660 phentermine tablets.
The state agency made similar allegations involving two other patients. It claims those patients were also receiving pain meds from other doctors and that Ramírez was not performing lab work and other requirements to administer such drugs. The complaint alleges gross negligence, repeated negligent acts, failure to maintain adequate and accurate records, and violations of provisions of the Medical Practice Act.
The state board has recommended that Ramírez’s license be revoked, but would stay that punishment for seven years while he completed a strict probation period. If he completed probation, he could get his certification back, but he said the litany of requirements would effectively end his practice as it now exists, by requiring he not operate as a sole physician.
A medical board spokesman said the agency could not comment as the complaint is still open. A hearing is scheduled for June 5.
“The proposal would end his practice,” said Dan Russo, an attorney for Ramírez who describes his client as a “saint.” “He’s putting his life on the line and they’re trying to blow up his office. He’s a solo family practitioner with a constituency of patients who are undocumented and don’t speak English.”
Russo also points out that the board’s investigation found one patient received opiates from 15 different Kaiser doctors as well, but the state has only pursued Ramírez.
“The only problem Dr. Ramírez had was charting his findings,” Russo said. “Also reporting requirements have altered since these patients. He has since taken an approved course in record keeping and he has amended his practice.”
But Dr. Jeoffrey Gordon, a retired doctor who previously served on the state board and regularly monitors physician accusations, reviewed Ramírez’s case and said he was alarmed.
“I can’t go to bat for him being the Joan of Arc of doctors, unfortunately,” he said. “His work appears to be very, very sloppy and perhaps negligent. They threw the book at him because they had lots of red flags,” said Gordon, a member of the California Physicians Alliance.
Ramírez acknowledges that his medical notes could have been more detailed, but he denied dispensing pills negligently. There are no allegations of his profiting off the prescriptions; Russo said the doctor simply wrote the scrips and patients would buy the medication at a pharmacy.
His practice, Ramírez said, has obstacles that most other doctors don’t face. For instance, while regulations might call for a patient to get a drug screening, many he sees can’t afford a $200 test or a $2,000 MRI to document a neck injury.
“That is the misunderstanding,” he said. “They don’t take into consideration what challenges a small clinic faces. They think every clinic is running a pill mill, but that’s not the case.”
As the line outside Ramírez’s office slowly shortened, four previous patients called in to the clinic to report that they had tested positive for the coronavirus. The news added to the doctor’s uneasiness of operating during the pandemic.
Ramírez gives his patients who test positive his private number and they call him often for advice and reassurance. After he treats a possible coronavirus patient, he prefers to clean and sanitize the examination room himself, his wife said.
“In order for me to be there, I need to be healthy,” he said. “There’s a lot of anxiety. My medical assistants all have kids.”
Of the 26 patients who waited hours to see him this day, five would leave the clinic with letters to get tested. Of those, the clinic would learn, two tested positive and one negative; two others declined to get tested, Furtado said. In all, she said, of 23 clinic patients who have been tested, 18 have been positive.
“I think the doctor has a pretty good clinical diagnostic sense with this,” she said.
The steady flow of needy patients would continue the next day, when the clinic would see another 27 people. But so many more had to be turned away that Ramírez decided to open the clinic on Saturday. He saw another 15 that day. A few days later, the doctor treated his final patient around 6:30 p.m., well after the usual closing time. He would write two more letters for virus tests.
The next morning, the line along International Boulevard began forming at 6 a.m. By the time the doors opened three hours later, the clinic’s caseload was booked for the day.