“If she was my mom, I would take her to the hospital,” Dr. P.J. Parmar said through a barely cracked car window to a refugee family from South Asia on April 11.
Parmar, who runs Ardas Family Medicine in Aurora, had been the family’s doctor for years. He knew the woman sitting in the backseat has diabetes, lives in a crowded apartment and likely has the coronavirus.
When the car pulled out of the parking lot, Parmar knew he might not see her again. A memory from his childhood in an immigrant family flashed through his head.
“I had like 20 addresses by the time I was 20,” Parmar said. “And I developed this ability to just walk away from something, thinking ‘That’s really sad, but I just have to walk away from it.’ I hadn’t had that feeling in years.”
Since the coronavirus crisis hit Colorado, Parmar estimates his staff of 10 has tested close to 300 refugees for the new coronavirus, with 45% coming back positive. One of the patients died. At any given time, he said he has 12 to 20 patients in the hospital battling the coronavirus, though that number is likely higher because he isn’t always notified when a patient is hospitalized.
Parmar’s clinic is located on East Colfax Avenue in the Mango House, a building he also owns that holds a dental office and a dozen small businesses run by refugees. All the shops and restaurants in the Mango House have temporarily closed due to the coronavirus crisis, but the clinic has never been busier.
Before the outbreak, Parmar said his medical practice saw 50 patients a day. Now, it’s closer to 70.
“They’re coming in because they’re scared, because word has gotten out that we have testing, because they know that we’re a place that they can quickly and readily go, and they don’t want to go to the ER.”
As of Tuesday, Colorado health officials reported that more than 10,400 people are positive for the new coronavirus. The coronavirus is statistically more prevalent among racial minorities in Colorado, according to initial data released by Colorado’s health department on April 13. But the state isn’t tracking the virus specifically in refugee or immigrant populations.
“We know that social and health care inequities affect outcomes, and that becomes even more apparent in times of disaster,” Jill Hunsaker Ryan, executive director of the Colorado Department of Public Health and Environment, said in a news release.
Parmar said there are a handful of factors that contribute to the high percentage of positive coronavirus cases he is observing within Aurora’s refugee populations — which is more than double the 21% seen overall in the state.
“These communities I’m helping, it’s kinda like they are on a cruise ship,” Parmar said. “Basically, they can’t really get away.”
He said many refugees often live in close quarters, with family members or friends or other refugees, due in part to the high cost of living in the Denver metro area. He also said his patients face increased risks because many rely on public transportation and are essential workers.
“Everything from meat cutting to packing to the grocery stores,” Parmar said. “They are all lower income jobs. They’re not exactly ones you can sit at home on your computer and phone and safely do your work.”
He said some are coming in saying they are scared to go into work. “Some are pretending to be ill,” he said. “Some hardly have to pretend.”
Like most other health care providers, Parmar’s clinic needs more personal protective equipment, including N95 masks, disposable gowns, alcohol wipes and latex gloves. But he’s been able to secure a steady supply of coronavirus testing kits from a lab in Florida and receives results in three to five days.
In terms of personal protective equipment, he said he’s doing the best he can.
“I don’t have anywhere near enough to switch it out between every patient or even every hour,” Parmar said. “So am I shedding virus as I take off the gown and go between cars and patients and bringing it home? Probably. Is there some fear in that? Yeah, definitely.”
The era of “parking lot medicine”
Most of Parmar’s day is spent on the phone, swabbing noses in the parking lot, or trying to find patients’ medical records in their system.
“Their names are often different than what they call themselves, or what’s on their green card, or on their Medicaid card,” Parmar said. “So it can be difficult to find them in the system. That’s something we struggle with all the time.”
During the day, the small medical staff sits at tiny tables pulled 6 feet apart in the entryway of the Mango House, answering phone calls and texting patients with their coronavirus test results. The team performs most exams out in the parking lot, and they even draw blood. Since the clinic doesn’t take appointments, people frequently wander up to the door looking for care.
The cost for care for someone who doesn’t have insurance is $20. Parmar said about 90% of his patients are on Medicaid, the state’s public insurance option for low-income individuals. The co-pay for these patients is $2.
The clinic doesn’t advertise. Clients learn about it through word of mouth or from recommendations from other organizations. Parmar said Denver Health has a refugee health program, but it’s difficult for some to navigate. He said his clinic is focused on accessibility.
“We don’t take appointments. We’re open evenings and weekends,” Parmar said. “So people just know that they can just come in and get care. It’s much, much, much, much harder to get an appointment and get to it on time at Denver Health or MCPM, which is now the Stride Health Clinics. We don’t have that problem.”
Parmar, who grew up in Chicago and moved to Colorado after college, opened Ardas Family Medicine in 2012.
“I wanted to work with underserved patients, and being an immigrant myself who faced a lot of the same issues that immigrants face, even though I absolutely am not a refugee and I came to the country when I was one, I still faced a lot of the racism and so forth,” said Parmar, whose parents emigrated from India. “I wanted to work with that immigrant population and underserved populations, and the most underserved are refugees.”
His clinic takes a somewhat unconventional approach to American medicine: social health care as a private business.
“P.J.’s clinic is different from other clinics in a couple of ways,” said Raz Al-Jaf, a 22-year-old medical assistant who works at Ardas. “One, he is not avoiding Medicaid patients, like other clinics do. And that serves our refugee community well because a lot of them, when they come into the States, first of all, they don’t understand how insurance works.”
“They think they can just walk to the doctor and if you need a surgery you pay like $100. But here, it’s a lot more complex,” said Al-Jaf, a refugee from the Kurdistan Region of Iraq who moved to Colorado four years ago.
Other practices often shy away from taking Medicaid patients because they don’t get as much money in reimbursements as they do from private insurance, Parmar explained. And typically, independent clinics or medical providers rely on funding from state entities, grants or nonprofits.
“And I don’t do it that way,” he said. “I’ve got to take massive loans out myself, and I’ve done that for years. The numbers in the end work, and anything else is just kind of a little gravy here and there, if it happens. … If someone throws some change in the jar, fantastic. If not, I’m doing it anyway.”
Mango House businesses face uncertain future
Any profits Parmar makes from the medical clinic, he funnels right back into The Mango House.
When the Mango House is in full swing, there are a handful of clothing stores open, an international grocery store, six restaurants, a tailoring shop, a Nepali jewelry store, and a place where refugees can get help with their taxes. On Fridays, there is a mosque that’s open from 9 a.m. to noon. And there is a big ballroom available for refugees to host fundraisers and other events. The ceiling of the food hall is adorned with flags from around the world, and the walls are covered in pictures of smiling faces, teenagers on hikes or on trips with the boys and girls scout troops that Parmar runs.
“You need to go get groceries from back home? You can go to the international grocery store,” Al-Jaf said. “You need some clothes? Go to one of the stores. You need dental care or medical care? It’s here. Everything is kind of set up to avoid as much confusion as possible for people who are newcomers.”
But all the shops and restaurants are currently closed due to the coronavirus outbreak, with the future of some unclear.
“They couldn’t sustain doing takeout, so they’ve just gone home,” Parmar said. “All the stores have basically closed. We had one grocery that was allowed to stay open and they tried for a while but their community was getting positive results from us.”
Parmar said many of the small businesses in the Mango House have been hit hard by the coronavirus outbreak, and many of his tenants are struggling to pay rent. “And that puts me in a strange position, of course, as the landlord,” he said.
“I don’t know how much to try to forgive rent or give a cut on rent, because that’s not easy for me, either,” Parmar said. “I have to pay the mortgage, too, and these things all add up. There are a lot of unknowns. I don’t know what this is all going to look like.”
Like most small business owners, Siri Tan, who opened Denver’s first official Burmese restaurant, Urban Burma, in the Mango House, is always thinking about the uncertain future. “I don’t know if it’s ever gonna be back to normal again,” he said. “That’s the hardest part, not knowing.”
Tan, who is originally from Burma, opened the restaurant last year and was forced to temporarily close due to the coronavirus outbreak. He says he looks forward to the day he can cook for his community again.
“I overheard one customer once say, ‘You’ve never seen real America until you go visit the Mango House,” Tan said. “You will see many different people here. You’ll see people from Africa, people from Nepal, people from Burma. People from all over. It’s really beautiful.”