Longtime readers of this column will not be surprised to learn that the town in question is Gonzales, the California municipal version of the Little Engine That Could. Its small, working-class population of just 9,000, many of them farmworkers, has ingeniously solved tricky local government problems, from universal broadband to health care access, and from economic planning to child development.

Now Gonzales is tackling one of our state’s most stubborn challenges: how to develop local sources of cleaner, cheaper, and more reliable power as our state’s aging energy grid falters.

Tiny Gonzales’s solution? Creating the largest multi-customer microgrid in California. In essence, Gonzales is building its own electricity island among the vegetable fields of the Central Coast to guarantee uninterrupted power, from mostly renewable sources, for the agricultural and industrial businesses that provide the tax base to support its ambitious local programs.

The idea of microgrids—local power grids that can be separate or connected to the larger grid—is not new. In California, they are seen as tools to make electricity service more resilient and to better integrate renewable energy sources, like solar and wind, with the power grid. But efforts to establish microgrids face complex obstacles, from scarce financing, to regulatory barriers that prevent utility customers from sharing power across different grids, to opposition from established utilities.

What distinguishes Gonzales is how the town is bringing together different entities—a savvy start-up applying advanced technology and financing power to microgrids, big energy customers in agriculture and food processing, a new municipal energy authority, and a method for selling power capacity back into the state grid—to surmount those obstacles.

The effort is actually bigger than the town. The $70 million microgrid is the most expensive public works project in the city’s history, dwarfing a $5 million revamping of its Alta Street thoroughfare. But if the microgrid succeeds—it’s scheduled to start producing power next year—Gonzales could provide a model for other California communities, especially those in rural or outlying areas poorly served by the existing grid.

“People want to see if we can pull it off,” says Rene Mendez, Gonzales’s longtime city manager. “We don’t agree with the idea that just because you’re small, you can’t do something like this.”

The problems that drove Gonzales to build a microgrid are familiar across California. The poor reliability of our current grid poses serious problems for companies that depend on steady power sources to operate advanced technology—like the refrigeration and processing machines of the food producers in the Gonzales Agricultural Industrial Park.

PG&E, the investor-owned utility servicing Gonzales and much of Northern and Central California, is so far behind in maintaining the existing grid that many communities, especially in remote places, can’t get the upgrades to the equipment needed to reliably deliver additional power. It could take up to three years for PG&E to update the local energy infrastructure to offer service to any new agricultural-industrial facilities that might move to town.

And PG&E’s use of regional power shutoffs to prevent fires has made finding local power sources that won’t shut down even more urgent. During one 2019 shutoff, Gonzales lost power for two days, resulting in multimillion dollar losses for local employers. This month, a PG&E lawyer said that these intentional outages will continue indefinitely.

Officials spent a decade trying in vain to convince PG&E to upgrade its infrastructure around Gonzales before the city started working on a 2017 plan to produce local electricity with ZeroCity, a Monterey-area company that works with municipalities on energy resiliency, and OurEnergy, a Santa Cruz technical and engineering consultancy. Recognizing that its existing municipal utility couldn’t afford to finance a microgrid by itself, in 2018 Gonzales formed a municipal energy authority that could enlist private financing and overcome some regulatory blocks.

Last fall, Gonzales agreed to work with Salinas-based microgrid developer Concentric Power to design, build, own, operate, and maintain the new microgrid. Concentric will also fund most of the project’s $70 million price tag, earning back its money over 30 years by selling power on a wholesale basis to the city’s new utility. The new Gonzales Electric Authority will contribute about $10 million, and take ownership of the distribution assets. The municipal utility will sell the power—at retail rates lower than PG&E’s.

About 80 percent of the power will come from renewables and about 20 percent from natural gas (which could eventually come from a renewable gas facility the city is also pursuing). The microgrid includes a substation that will allow the sale of excess capacity into the state system, or to Central Coast Community Energy, which serves residential customers in Gonzales.

Effectively, Gonzales is betting that its new microgrid won’t just keep existing food processors in town, but also will make it easier to attract other companies, strengthening the tax base that supports its civic innovation. Additionally, the microgrid should supplement the two giant wind turbines that tower above Gonzales, local landmarks that already serve local food processors. A third turbine might be in the offing.

“This is a community scale microgrid business model that hasn’t existed in the past,” says Salinas native Brian Curtis, founder and CEO of Concentric Power, which is already working on microgrid projects in the Central Valley and elsewhere in the Central Coast. “It’s going to be a watershed project for the state.”

Should the Gonzales microgrid launch and successfully serve multiple customers, it will be a powerful example of local power, especially for rural communities trying to protect or grow industry. Most microgrids serve a single customer or landowner, or are owned by utilities themselves. (In addition to Gonzales, microgrid believers also point to the Redwood Coast Airport microgrid in Humboldt County as a potential model for more powerful, multi-customer microgrids.)

In recent years, California has funded microgrid pilots—from the Blue Lake Rancheria tribal land in the far north to Borrego Springs in northern San Diego County—but it has struggled with the complicated task of creating a regulatory structure that would incentivize localities to produce more microgrids. One especially difficult issue is how to create a system of “microgrid tariffs” to govern how costs and benefits of different grids are shared.

By building its own microgrid, Gonzales is refusing to wait for the rest of California to get its act together. In so doing, one of our state’s smallest towns is, once again, setting a very big example.

The post The Huge Electric Leadership of a Small California Town appeared first on Zócalo Public Square.

Rural food banks, like the one I work at, have an outsized importance, because there are fewer food options in smaller places. And while we are far from big cities like Los Angeles, where I lived until moving up here 12 years ago, we are in the middle of the pandemic’s challenges around poverty and health. So many people here in Kings County are in need of food in these times—including, ironically, farmworkers and others whose jobs involve food.

Our food bank is tiny—with just 2.5 employees (including myself). With a yearly budget that hovers around $150,000 for food, we are dependent on community support, donations, and volunteers to do three to four distributions a week. The pandemic has brought us more resources and more food—but also so many more people to feed.

Our food bank is just one small piece of Kings Community Action Organization, the non-profit organization that is also the federally designated anti-poverty agency for Kings County (population 152,000). KCAO’s main office is in Hanford, the county seat, but the food bank operations are in Lemoore.

Before COVID, most people would just walk up to our partner sites throughout the county, but now everything we do is drive-through. We’ve added more hours to our distribution, given out food at later hours, and also added some distribution on Saturdays.

As the pandemic deepens, our volunteers have noticed more families showing, many of them in nicer trucks and SUVS than we’re used to seeing. More people tell us that they had never expected to need the food bank, until they do. We’re seeing more emotion, as people cry in gratitude.

We’ve watched the need grow quickly among farmworkers, in particular, so much so that we have begun doing special food distributions just for them, where they live. One distribution even took us out to the fields—providing food where the food is literally grown. We bring much more than food when we do a distribution—we’re delivering PPE, hand sanitizer, and, more recently, some holiday tchotchkes and information about COVID vaccines.

I’ve been working at this food bank for the last four years, and fundraising is a constant part of the job. I have noticed that the past year has been good for grant writing, with new funding from the United Way, Bank of America, Southern California Edison, and from local community members. But most of the time, money is harder for rural banks; we don’t get the financial support that food banks in big cities like San Francisco and Los Angeles get from big companies, because there aren’t big companies here to sponsor you or your fundraising event. In more rural parts of the state, the bigger regional food banks receive more donations.

Our food bank, like many rural food banks, relies heavily on food provided through a federal program known as TEFAP (The Emergency Food Assistance Program) that supplements the diets of Americans with lower incomes through low-cost food. USDA provides food and administrative funds to states to operate the program and make deliveries to food banks like ours. We’re always careful to keep an inventory of two or three months of food, just in case there’s ever an interruption in the supply.

The demand in the pandemic has been intense—for every kind of food. We just had two distributions in one day—the first in Stratford and the other in Kettleman City where we provided not just food but water, because those communities have issues with water quality. We were averaging 55 families in those communities previously, but we had 200 families for these distributions.

With so much closed during COVID, we have a little more work to do in terms of finding locations for distribution that are actually open, but churches and community centers generously offer their space and parking lots. As the pandemic continues, we’ve also found that many people who used to deliver food to their own relatives no longer can, because someone has COVID or is isolating at home, Fortunately, Kings Cares Essential Workforce Support Program assists currently COVID-positive families. (There is comprehensive support to help essential workers isolate or quarantine safely, at home or in a hotel; healthy food, cleaning supplies, toiletries, transportation and laundry service, and utilities/housing assistance are all available.)

While this time is challenging, I worry it may be even harder for rural food banks when the pandemic is over. While the need for food could remain extra high, I fear that food donations and financial support may not be enough to keep up.

So don’t forget about us.

You can help us even if you don’t live nearby—by calling your legislative office to remind them how important food banks are in places where there are fewer food options. We also welcome donations from anywhere. And if you’re up for a trip, let us know. We can always use volunteers.

The post Rural Food Banks Have Never Been More Important appeared first on Zócalo Public Square.

On my first night in town, I was hooking up the television for my children and by sheer coincidence received a fragmented radio signal through the TV receiver from the sheriff’s office: There was an emergency, and they needed medical help. I found the sheriff’s office and was promptly whisked to the scene of the crisis—a car resting precariously on an embankment 150 feet below the road, with an unconscious person inside. I was lowered down by a tow truck cable, then secured the vehicle and started the patient on an IV. He was lifted back up on a Stokes rescue litter and taken by ambulance to the nearest hospital—in Grass Valley, 50 miles away.

The next day as I went through town, my adventure was all the talk. I wondered, “What have I gotten myself into?”

When I arrived in Downieville that day in 1976, there was virtually no consistent primary medical care or integrated emergency medical services response to trauma and medical emergencies. Some vagabond EMTs were just beginning to train with the fire department, and the local Lions Club had founded a fledgling medical care system. But an emergency like the one I’d attended depended on well-intentioned citizens getting into cars and trying to help out. No one knew what a nurse practitioner was; I lacked any credibility except what I could do for the ill or injured.

Luckily, I loved what I was doing from the start, and my work became our family’s story.

The National Health Service Corps (NHSC), which places health professionals in rural communities, had sent me to Downieville to open a health clinic. The deal was that the NHSC would pay my salary and clinical expenses for a couple years before the operation would be taken over by the community.

I started by building the clinic’s infrastructure: buying equipment, hiring a support staff, developing integrated referral processes to make it easy for patients to see specialists, and creating an emergency response system. Because of Downieville’s geographic isolation, the clinic staff needed to be able to treat a wide variety of illnesses and injuries; finding nurse practitioners and physician’s assistants to cover such a range was difficult, though not impossible.

My staff and I took supplemental classes at the UC Davis School of Medicine (a 2 1/2 hour drive away) to fill in gaps. To provide many of the services I added, I had to be licensed through the state and approved by practice boards. For example, we had no pharmacy in town, so we got licensed to dispense medication.

After the NHSC placement and funding ended, I decided to stay on in Downieville with the support of the community. I was able to secure funding for my salary through the California State Rural Health Association. I also wrote grants to foundations and nonprofits to purchase equipment: a defibrillator first, then an X-ray machine. Grants helped build up the facility over the years, but we still operated on a month-to-month basis.

The biggest issue was that running the clinic was a 24/7 commitment. My wife, who is also a registered nurse, began working in the clinic as a volunteer, and eventually received grant funding. She and I were raising three sons together, and we rarely were able to take any time off because it was so difficult to find people to come up to Downieville and cover shifts at the clinic. Some people I had trained at UC Davis would come up occasionally. The American Medical Association rural doctors program would send a doctor to the community for two weeks. After 22 years, we got external funding so that I could take two regular days off a week with another provider on call.

In 2007, our peak year, the clinic offered access to a nutritionist, physical therapy, and home care, and had substantial savings in the bank. But then the recession hit, our grants started to dry up, and state funding levels dropped. My wife went back to being a volunteer.

Over the past few years, Downieville has been caught up in changes for funding health clinics. Federal and state priorities have shifted from rural and frontier areas to underserved, urban population areas. When you do the math, the cost-per-patient equation will always come out in favor of a clinic in an urban area. As a result, a rural clinic must rely on the support of a larger, population-focused clinic—which doesn’t have any incentive to provide rural patients with better care.

In 2010, the number of patients we were seeing yearly decreased from 4,000-4,500 to 3,000-3,500, and we joined forces with a clinic in Grass Valley that sees 17,000 patients per year. Originally, the Downieville clinic was guaranteed continuing support for our 24/7 medical care. But while the larger clinic in Grass Valley expanded, our smaller clinic withered. Nutrition, physical therapy, and dental services were all cut. Behavioral health services are now accessed via telemedicine.

On October 1, Downieville’s medical care is scheduled to be reduced to three days per week, with no after-hours care or weekend coverage. This means, after that date, the community will no longer have critical care or advanced life support coverage, consistent urgent care, or end-of-life home care. There is a great deal of uncertainty about urgent care needs: Does an X-ray require the expense and time of a trip to Grass Valley? The integrated frontier healthcare delivery system I built over decades is being systematically dismantled; I worry that a patient will come into the clinic one day and be greeted by nothing more than an iPad.

The cutting of care has galvanized Downieville, and we have previously won delays in implementation of the reduced services. The clinic is going to join forces with other community partners, including the fire department, to develop an integrated 24/7 paramedic and clinic system. It won’t be ideal, but it is sustainable. And it will probably be paid for by the people it serves—with support from a western Sierra County health services fee for all landowners, increased user fees for community events, and higher ambulance fees.

Now, under the Affordable Care Act, everybody has insurance. Theoretically, this means people should have more access to healthcare. But that’s not true in Downieville after the changes of the last few years. More insurance won’t help people if healthcare treatments are inconsistent or unavailable.

One of the changes expected to take place under Obamacare is more reimbursement for clinics. But such reimbursement is based on the number of people served. There are not enough patient encounters in frontier areas like ours to be sustainable without grants or government funding.

The post The End of Frontier Medicine in California appeared first on Zócalo Public Square.

Paul Hensler, CEO of Bakersfield’s Kern Medical Center, said that the problem begins with a maldistribution of physicians: between rural and urban areas, between the Northeast and the rest of the country, and between primary-care physicians and specialists. But in addition to a shortage of primary-care physicians, the San Joaquin Valley is also facing a shortage of nurses, therapists, technicians, and clinical specialists. It’s a shortage that will only grow more acute with an influx of new patients as the Affordable Care Act comes into effect.

But solutions can be found locally, said Hensler. People who are raised in the area are generally more comfortable returning and staying here. To increase doctor retention, we must give bright local students educational opportunities, get them to medical school, and offer them residencies here. “Those are the kids who have the best shot of being the future physicians in the Valley,” Hensler said.

Catherine Dower, the associate director of the UC San Francisco Center for the Health Professions, mapped California’s supply of healthcare workers by profession and county. Her study found that for every one doctor who goes into an underserved area such as Kern County, four doctors go into a well-served area like Los Angeles or the Bay Area. So physician shortages are not being remedied. To make matters worse, “we actually don’t know how many people we need,” she said, because our calculations of the ratio of doctors and nurses to population are based on historical data.

Today, said Dower, new practice models and changing demographics are upending our ideas about how many practitioners we need—which isn’t a bad thing. Patients are getting good outcomes with differently structured practice models, particularly around primary care. Medical staffs are relying on nurse practitioners and physician assistants more extensively, and telemedicine is also beginning to deliver high-quality, more financially sustainable care. But Dower does believe that we can get much more diverse when it comes to doctors and nurses. “Our health professions don’t look like the general population,” she said.

Jarrod McNaughton, vice president of San Joaquin Community Hospital, is working “full bore” on physician recruitment to staff a new cancer center and to attract more primary-care physicians. But a few trends have presented stumbling blocks. Whereas previous generations of doctors were entrepreneurial, today, new doctors want to be employees of clinics or hospitals—and California hospitals are not allowed to employ physicians directly. Instead, they must create foundations and “go through a cumbersome rigmarole” to employ physicians. More physicians are also being dragged into hospital administration—which can be a good thing, but also means a lower number of total physician hours spent with patients. Also, internal medicine physicians are leaving private practice to become hospitalists, depleting the number of doctors who can see patients in the community. Finally, a local issue in Kern County has been “total market spend.” If you look at all the available healthcare dollars in the market, said McNaughton, a lot of them are leaving the county and heading south or to the coast.

John Arthur, executive editor of The Bakersfield Californian and the evening’s moderator, found ample proof for McNaughton’s final supposition by polling the crowd: Almost everyone in the audience had gone to Los Angeles, or had a relative go to Los Angeles, for specialized treatment they couldn’t get in Bakersfield.

But what is being done to keep healthcare dollars local—and to improve the community’s access to doctors?

Hensler said that it starts at the high-school level, by making students aware of opportunities in the health profession—and finding ways to address their financial concerns. He also said that the creation of a health sciences magnet program at CSU Bakersfield would be one way to address the shortage.

Arthur asked McNaughton if he is making an effort to attract non-white doctors to his hospital. “It’s a major community need,” said McNaughton. “The problem is, in a market that is so constrained for physicians, it can be very difficult to demand it.” It’s one of the top attributes he looks for in candidates, but it’s not possible to make it a prerequisite.

In the question-and-answer session, audience members asked the panelists to talk more about how they are facing the region’s particular challenges.

In response to a question about the Kern Medical Center’s family practice residency program—which was in danger of being suspended—Hensler said that the program doesn’t receive nearly enough financial support. Hospitals in the Northeast, he said, receive $200,000 per resident; the Kern Medical Center gets $17,000 per resident—and each resident costs the hospital roughly $200,000 to $250,000 beyond stipends received and revenues generated. Philanthropy can make up this difference, but the hospital is also looking for a more collaborative, community-based program that can work in the long term.

What can be done to put more of a focus on healthcare prevention in Kern County—which could take some of the burden off doctors?

Dower said that in other underserved areas of the country, teams that include nutritionists and community health workers are doing preventative work, which is especially helpful in handling our growing chronic disease burden.

But, said McNaughton, there is still the underlying problem of an American medical system that rewards testing and procedures rather than wellness.

Another audience member asked the hospital administrators to talk about how they recruit doctors to Bakersfield, given what he called “our unhealthiness and lack of aesthetics”; does a perceived lower quality of life here affect recruitment?

“It’s a major problem,” said Hensler. He’s had physicians interested in the opportunities afforded by Bakersfield only to have their spouses dissuaded by problems like the area’s poor air quality or Valley fever. But, he said, these things are cyclical: “The environment is critical: A. to a healthy population, and B. to recruit the professionals we need to bring in.” He talks to doctors at UCLA who say that one-third of their patients are from Bakersfield. If Bakersfield could get those doctors to stay in the community, it would create jobs and revenue within the community—which would in turn improve the community. “It’s all interconnected,” he said.

The post Can Bakersfield Find Doctors Who Won’t Run Away? appeared first on Zócalo Public Square.

It’s one of the state’s sickest regions, with high rates of obesity and diabetes and an epidemic of asthma. It’s one of the poorest regions in California, which hardly makes it lucrative for new doctors looking to pay off student loans. And it has the worst air quality in the country.

Not surprisingly, the Valley has far fewer primary-care physicians and specialists than are recommended by nationally recognized benchmarks. Where the recommended number of primary-care physicians is 60 to 80 per 100,000 people, in the San Joaquin Valley that number is only 45 per 100,000, according to a 2010 California HealthCare Foundation report.

That’s why I listened with particular interest to an NPR report earlier this year about Benjamin Anderson, CEO of a health center in rural, southwest Kansas. Like the San Joaquin Valley, Anderson’s corner of Kansas doesn’t naturally attract scores of physicians. It’s an agricultural community of about 900 people, located about an hour from the nearest Walmart, two hours from a Starbucks, and three hours from a big city, Wichita.

Yet Anderson has managed to turn around his organization, the Ashland Health Center, and improve service to his community. When Anderson joined Ashland almost four years ago, it was in a fragile position. Employee turnover was high, morale was low, and finances were upside down. Since then, Anderson has recruited one nurse practitioner, one physician assistant, and two doctors to join a solo mid-level provider.

I called Anderson to learn more about his approach. He told me there are four types of doctors that are willing to work in medically underserved communities: There’s the local person, who was born and raised in the area. There’s the foreign physician, who earns a work visa, stays for the required amount of time, and then transfers to a more desirable location, like San Francisco. There’s “the troublemaker,” a doctor with personality or quality issues who is tolerated in communities where the need for medical professionals is dire. And then there’s the mission-driven idealist.

It is doctors in this last category for whom Anderson searches. These are people who feel called to care for the underserved, both locally and abroad. To sweeten the deal, Anderson offers even more of the same: time off to practice in other parts of the world. All of his medical staffers get eight weeks of paid leave each year, and many have used it to provide healthcare and service in Africa, Asia, and Latin America. “We appealed to the physicians’ sense of mission,” Anderson explained. “If you’re willing to live and serve in a mud hut in the African bush, chances are you don’t need a Nordstrom or a Starbucks or a big airport nearby. You’re there to serve.”

I asked Anderson if he thought his approach would work in the San Joaquin Valley. “I think it works really in any underserved area, and the Valley is no exception,” Anderson said. “The same people that want to serve internationally in developing countries have a heart for people here.”

To be sure, the Valley already has several excellent, innovative programs at the high school, college, and medical school levels that are designed to train doctors to treat the region’s specific healthcare needs and diverse communities. This fall, Governor Jerry Brown signed AB 589, which creates a scholarship to help cover the cost of medical school tuition for doctors who commit to practicing for at least three years in one of the state’s more than 200 medically underserved areas. (The bill’s sponsor, Henry T. Perea, told me he hoped it would “spur more homegrown doctors to seek their medical training and then come back home.”)

But when it comes to retaining doctors in a place like the Central Valley, I agree with Anderson: The doctor who will stay has to be someone with a mission—someone who is driven by compassion and a desire to care for poor families, immigrants, and agricultural workers.

It’s someone like 20-year-old Stephanie Huerta, who grew up in Caruthers, a small, agricultural community in Fresno County. While a student at Caruthers High School, she participated in the UCSF Fresno Doctors Academy, a rigorous program intended to prepare Valley youth to become culturally and linguistically competent health professionals for the medically underserved region.

“It’s always been my dream and my passion to come back,” said Huerta, who today is a junior in college and on the pre-med track at UC Santa Cruz.

She knows doctors in the Bay Area are paid more, but she’s felt her home region’s need for doctors personally. She remembers long waits in the doctor’s office when she was pregnant with her daughter and an endless wait in a Valley emergency room when her fiancé broke his nose. “It’s not just about money,” she said. “It’s about caring for people.”

And it’s someone like medical student Agustín Morales, the Mexican-born son of immigrant strawberry pickers. In 2011, he joined the first cohort of the UC Merced San Joaquin Valley Program in Medical Education, a collaboration between the University of California, Merced, and the UC Davis School of Medicine. “I think that the level of quality and access [to healthcare] should be the same, whether you are the CEO of a company or you are a farm laborer, just like my mom or any of my relatives,” Morales told me last year. “We all deserve to be treated with dignity.”

Doctors and students like Huerta and Morales would probably be receptive to a San Joaquin version of the incentives Anderson is trying out in Kansas.

Certainly, Anderson admits his approach to recruiting doctors is not traditional. “It really rides the edge of many people’s comfort level,” he told me. But it’s been successful. We need a fresh approach to recruiting and retaining health professionals, and Anderson’s tactic may be an effective way to attract young, passionate doctors to rural areas.

“From my experience, millennials are more driven toward issues of social justice than any generation in American history,” Anderson said. “If you can appeal to their sense of mission, you’ll attract them. No amount of money replaces that.”

The post Will High-Caliber Doctors Practice In Low-Appeal Places? appeared first on Zócalo Public Square.

The Valley’s health problems are well-documented. John Capitman, executive director of the Central Valley Health Policy Institute, called its scores on the nation’s 10 leading health indicators (e.g., obesity and smoking rates and air quality) “a sad story.” The region meets national standards in only a couple areas, one of which is physical activity, thanks to its many farm laborers. But 40 percent of its adults are overweight or obese, while the national standard is around 15 percent.

These health problems are also deeply ingrained. When, asked moderator and KQED health reporter Sarah Varney, was the area at its healthiest? Capitman said that even in the 1970s the Valley performed worse than California and the nation, “but a little bit less worse.”

Sarah Reyes, the California Endowment’s Central Valley program manager, argued that the problems are bigger today only because the population is higher. “We have always been worse off than other parts of California,” she said, pointing to high poverty rates, a large immigrant population, and the region’s poor air quality.

However, said Capitman, certain demographics–insured and educated white men, for example–are healthier than the state or national averages. The problem lies in disparities that aren’t being addressed by our current healthcare system.

That system hasn’t changed since the 1970s, explained San Joaquin Valley Rehabilitation CEO Edward C. Palacios, and as a result people don’t know where or when to get healthcare. As a hospital administrator, he said, “We can deliver care and education to the people who access us, but how do we go out to educate others?”

The Central Valley’s large undocumented population is particularly challenging to reach. Many illegal immigrants rely on emergency-room treatment–the most costly option but also the only one that’s guaranteed by federal law, since ERs are prohibited from turning anyone away. We’re hiding from this issue, said Capitman, and even though the Affordable Care Act has the potential to insure a million more people in the region, it won’t help undocumented patients.

Even when organizations have aimed education efforts at the region’s lower-income residents, they’ve struggled to succeed. Reyes said that lecturing people about exercise hasn’t worked in the past, but the California Endowment has had success with increasing people’s access to it. It has sponsored boot camps with local boxing champion Jenifer Alcorn at Fresno’s public parks that are drawing large crowds on the weekends.

Hospitals are taking a similar approach. “We’re going beyond the hospital walls and finding out where the community resources are and trying to make those connections,” said Palacios. It doesn’t stop at finding someone a wheelchair, he said. We also need to make sure the patient is going home to a place with wheelchair access.

Education and access go hand in hand, said the panelists. Capitman has found that young mothers don’t take advantage of prenatal care because they find it “culturally inconsiderate and downright insulting.” Warning these women that they can expect to be insulted–and also why prenatal care is helpful and what they can demand from the system–goes a long way.

When it comes to getting people to eat healthier, said Reyes, the presumption is that building a grocery store in a neighborhood that’s a food desert is enough to solve the problem. But grocery stores are front-loaded with junk food, and many people don’t know how to prepare fresh fruits and vegetables. The California Endowment is working on storefront conversions to move junk food to the back and healthier options to the front, while Fresno County’s Economic Opportunities Commission is sending dietitians into grocery stores with mothers.

“The challenge and the opportunity is to take advantage of how we access people,” said Palacios. We can take advantage of cell phone and smartphone use to reach people, he said–or Facebook, added Reyes.

But Capitman believes that the problem lies still deeper–and isn’t limited to the Central Valley. “It’s about getting a shift in our cultural conversation,” he said. The Central Valley’s failing health “is just a symptom of a larger process where we’re allowing communities to fail.”

In the question-and-answer session, audience members asked the panel what’s next on the education and policy fronts. What’s the tipping point in convincing the masses that healthcare change is needed?

Palacios thinks that many movements are working independently and instead need to share their work with one another. Reyes said that people should start by admitting that there’s a problem that goes beyond personal responsibility. “The tipping point comes when folks realize it’s not a level playing field,” she said.

Can California move ahead if the federal healthcare reform law changes? Yes, agreed the panelists. Long before the Affordable Care Act came to the federal level, said Reyes, California was already working on reform.

Watch full video here.
See more photos here.
Read expert opinions on how to improve the health of the Central Valley without increasing government spending here.

*Photos by Dalton Runberg.

The post The Central Valley Is Fine If You Don’t Eat, Breathe, Or Get Sick appeared first on Zócalo Public Square.

Moderator Michelle Levander, director of the California Endowment Health Journalism fellowships, opened the discussion by presenting some bleak statistics about the inequalities of healthcare in the Central Valley. In the region’s poorer zip codes, the rate of premature death is double that of its higher-income zip codes. And the range in life expectancy from poorer to wealthier areas is as wide as 21 years. “These are really issues of a shared destiny,” said Levander.

Dr. Marcia Sablan’s patients at her clinic in rural Firebaugh–50 miles from Fresno–deal with transportation issues and specialist shortages on a daily basis. Take “a common, everyday care of gallbladder disease,” said Sablan. A patient with private insurance will have his or her gallbladder removed in a week or two. Someone with Medi-Cal will have the procedure in a few months, after a few trips back and forth to Fresno (which winds up costing about $100 per trip). And someone without insurance, who has to see the doctor at the local safety-net clinic, won’t get an appointment for “months and months.”

Gallbladder disease isn’t usually fatal, but Sablan frequently sees patients whose lives are put at greater risk as a result of delays in treatment of such problems. One, a 30-year-old woman, learned she was pregnant just before a sarcoma was discovered growing on her leg. She died after spending two months waiting to be transferred to a hospital that could treat her while she was pregnant. “I’m ashamed of our medical care situation,” said Sablan. No one can say she would have been saved elsewhere, “but at least she would have had a chance.”

San Joaquin Valley-based community health reporter Rebecca Plevin has found that transportation is “a huge issue” for the doctors and patients she meets, from a pregnant woman who had to take an hour-long ambulance ride after her contractions started to school nurses who report students who are unable to get the glasses they need. “There are clinics that will bring in specialists to avoid patients traveling,” said Plevin, “but it’s still a big barrier.” And although there is a strong network of local clinics and many access points to healthcare, it’s often difficult for patients to get to where they need to go–and to be able to afford to take off work for appointments.

Policy changes are also affecting healthcare in the region. For example, the Healthy Kids Program–a children’s insurance program intended for children who didn’t qualify for state-funded healthcare programs due to immigration status and family income–lost its funding last year. Sablan pointed to a stopgap in the form of Medi-Cal’s gateway program for children without immunization or physicals–but it only covers children for a month.

Herrmann Spetzler, the CEO of Open Door Community Health Centers in northern California’s Humboldt and Del Norte counties, offered one possible solution: telemedicine. It’s “a tool for getting over the mountains and getting that care that we need, or that connection to urban areas where the centers of excellence are always going to be,” he said. Telemedicine connects his clinics to doctors at UCSF and UC Davis, among other places. In the case of an eight-year-old girl with an undiagnosed seizure disorder, her caretaker, her local pediatrician, and two specialists in Los Angeles and Phoenix were able to analyze her condition together thanks to the technology.

“We are all over the state, because no longer is the geography an issue,” said Spetzler, who thinks that telemedicine is the future of rural healthcare. “It’s an economic development opportunity that this next generation of medical providers will have at their fingertips.” He added, “We can focus totally on the woe of how poor the distribution of healthcare resources is between rural and urban [communities]. Or we can look at what opportunities we have to go ahead and use modern technology.”

Technology also helps address the perennial problem of recruiting doctors to rural areas, said Spetzler. His clinics have one infectious disease doctor, but she meets regularly via telemedicine with three other rural doctors–who can even be on call to relieve her while she’s on vacation.

Pipeline programs are addressing this issue in the San Joaquin Valley, said Plevin. One is the Doctors Academy, which tries to increase interest among middle and high school students in joining the medical professions, encouraging them to go on to study medicine in college and beyond–and to return to the Valley. UC Merced and UC Davis also have a new program that studies the needs of the area and trains students to work there, while UCSF Fresno brings students to the Valley for their residency. The idea is to “train doctors who will be familiar with the needs of the Valley and who will want to stay here and practice here,” she said.

These programs are the answer, and our hope for the future, added Sablan.

Watch full video here.
See more photos here.
Read more stories from rural doctors here.

*Photos by Esteban Cortez

The post Last Doctor For 50 Miles appeared first on Zócalo Public Square.

In cities, more and more of us are getting used to getting medical care that treats us as a collection of parts. We see a podiatrist for our foot, an ENT for our ear, a cardiologist for our heart, a gastroenterologist for our gut. If we’re lucky enough to have a primary care doctor, we still expect to see him or her exclusively in the office. But in rural areas, you’ll probably see a general practitioner, not a specialist, and you’ll meet your doctor at school plays, the supermarket, or on the sidewalk. And what’s it like for the doctors? What do they experience in the hinterlands that city-slicker doctors don’t? In advance of “Does Rural Healthcare Have a Future?“, a Zócalo event in Fresno, we asked several rural doctors to share their experiences.

Adjusting to the Mississippi twang

The drawl was unmistakable. It was long, rich, and seemed to have stories untold in it. More important, I had no idea what my patient had just said. It was my first week working in rural Mississippi as a family doctor, and all the warnings that my colleagues in Detroit had given me kept ringing in my ears. I could not seem to get a decent history from him. Was I doomed as a family doctor? Was it ridicule that I heard in his voice?

Time passed. I stuck around and built a practice that was as varied and challenging as any I had imagined. Slowly, I was integrated into the workings of the small town and countryside–the football games, the crawfish boils, the school plays, and graduation. That was the backdrop of all clinic encounters, the context for the pictures being described.

The work seemed to flow from clinic to hospital, from homes to school clinics. The key context was that of the “community.” I was like an essential monument in town–“Doc.” It seemed like I had come a long way from fearing “The Drawl.” And then, in the middle of shrimp season, I heard a voice through the back door of the clinic. It was the patient with the strong drawl again–this time I understood it–dropping off a gift, several pounds of fresh shrimp, “for the Doc and the clinic.” We got to talking, and he mentioned that he was thankful that I was taking care of his kin–a cousin with depression, a grandson with asthma, his Maw-maw with arthritis, and his Pa with a “bad heart.” I looked at the clinic appointments. I had seen 6 generations of his family in the past month. I thanked him for the gift: that night, my family cooked up those delicious, fresh-caught gulf shrimp.

Fewer silos, more community, more comprehensive primary care–these are what I remember of my time as a rural doctor. As we discuss the future of health care delivery, I think about building community and planning for local needs. We need to understand the backdrop, the colors that enrich the lives of the folks we work with.

Dr. Shailendra Prasad is an assistant professor in Family Medicine and Community Health at the University of Minnesota. He also works with the Rural Health Research Center there. He has worked in underserved rural and urban areas as a physician for the past 20 years.

————————————-

Great are the joys, great are the pains

When I moved to far-northern New Hampshire to practice family medicine, my wife, Pat, and I were fresh out of residency. Pat had been raised in rural Vermont, so she knew the terrain. I had been raised outside of New York City but had long known that my heart’s spirit was in the mountains. I was a hiker and climber, not yet a hunter or fisherman, and I longed to learn. Fly-fishing, in particular, sounded wonderful; it seemed like an athletic dance, a communion rather than a contest. I wanted this and waited for my chance.

Fortunately, the business and civic leaders in rural New England towns know the importance of having the right doctor in place. The local bank got us started with a reasonable loan and a mortgage, and the bank president himself, who was also on the board of the local 35-bed hospital, helped us get established. His name was Ron Carpenter, and, as luck would have it, he was also a fly-fisherman. Ron offered to take me out that spring, when the season began.

That first winter was the worst in a decade, with 18 inches of snow by Thanksgiving and a number of weeks in January and February when the temperature didn’t climb above zero. Mud season and maple sugar season and town meeting took forever to arrive, and the early daffodil buds seemed impossibly beautiful. Ron and I made plans for my first fly-fishing trip, and I began to dream fish dreams. Until that Tuesday night when the phone rang, and Pat and I somehow knew from the ring that there had been an untimely death and that we, as deputy medical examiners, would have to help the cops clear a death scene.

At first, I wasn’t sure it was Ron. The driver’s face was mangled beyond recognition. He’d been taking the baby-sitter home and struck by a drunk yokel driving on the wrong side of the road as they crested the hill. But I knew for sure that it was Ron when I saw his son Jonathan, dead but still beautiful, in the back seat.

In rural practice, our roles as doctors are interwoven with our friends, our patients, our colleagues, even our adversaries. Usually, there is joy when delivering their babies or satisfaction in easing their passage to death after a life lived long and well. And occasionally it hurts more than seems bearable. Thirty years later, I still wait for the right moment to learn to fly-fish.

Don Kollisch is a family physician who began his career in rural New Hampshire. He has taught and practiced at UNC-Chapel Hill and the Dartmouth Medical School, and now works as a Deputy Dean at the Sophie Davis School of Biomedical Education at The City College of New York, a medical school with a social mission.

————————————-

Patients are friends and friends are patients

Rural physicians have an advantage over our urban counterparts: we know our patients in multiple contexts. Cindy Jones isn’t just the 42- year-old with hypertension that has recently been difficult to control. She is also the mother of Jacob, who is having trouble in school and is currently benched because of grades, and the wife of Bill, who recently lost his job when the employer he works for pulled up stakes and left the community. Jacob and Bill are probably also our patients. And our neighbors. And our children’s schoolmates and teammates. Seeing our patients both in and out of the office means we already know a lot about them and have a strong sense of their backstories when they come in as patients.

Knowing our patients outside the office also means that the barriers between physicians and patients are lower. Patients feel comfortable asking a minor health question at the local ball game or in a Facebook message or text. While some city physicians may feel uncomfortable with the idea of contact with patients outside the office, in a rural setting it is uncomfortable not to talk to patients in the community. I have often told my urban colleagues, “If I am not friends with my patients, then I either won’t have friends or won’t have patients!”

Lowering barriers and increasing context means that physicians can provide better care. Care can be timely, so minor problems don’t become major. Care can be individualized, so patients receive treatment specific to their circumstance. (In Cindy’s case, it meant that a talk with a local therapist did a lot more for her blood pressure than one more medicine in her pillbox.) Most of all, care can be comprehensive, so patients are treated across the spectrum of their health and in the context of family and community values.

Dr.Jen Brull is a family medicine physician in solo practice in Plainville, Kansas. She obtained her medical degree from the University of Kansas School of Medicine and completed family medicine residency training in Topeka, Kansas.

————————————-

Goodbye, Old Walls

Before I moved to the Berkshires, a rural area in western Massachusetts, my training and experience as a psychiatrist took place in urban settings, where I rarely encountered patients outside of my practice. However, in a rural area, contact with patients in the community is constant and inevitable.

The encounter that inspired this poem occurred after my first day of work at Berkshire Medical Center, our local community hospital. At the time, I was a distance swimmer and in the pool every day. This is the second poem I wrote in honor of William Carlos Williams’ famous poem “Spring and All.” Williams, who was a doctor-poet, is one of my heroes. “A new world naked” is perhaps the best-known line from the poem.

“Spring and All,” Revisited (Again)

My mentors taught me anonymity,
to be a blank screen, to reflect
and hear the space between
my patients’ words and their sighs,
to notice the moment our eyes lost contact.
And when I had learned my lessons well,
I moved to a small town hospital
where I drove to work one cold March morning,
like the time Doc Williams stopped
on his way to the contagious hospital
and called spring “a new world naked.”
Oh, the secrets I heard before I peeled
off my white coat and crawled
through the water at the local pool,
my flesh cleansed in the chlorine water,
my last patient of the day soaping up
when I entered the shower, how he reached
through the spray for a handshake,
a new world, naked.

Richard M. Berlins most recent book Secret Wounds, published by BkMk Press, won the 2010 John Ciardi Award in Poetry and was selected by USA Book News Awards 2011 as the best general poetry book of the year.

————————————-

Delivering the right kind of care in Greeley County, Kansas

When I left my family medicine residency program, I went in search of a position where I could be the old Marcus Welby-style generalist, the doctor who did it all, from prenatal care to palliative medicine and everything in between. I’m also board-certified in preventive medicine and public health, and I wanted to work in community-oriented care. I loved the city where I’d trained, but it was very difficult to find an urban practice that fit all my interests. With the increasing dominance of medical specialists, city people think Marcus Welby died a long time ago, as their bodies have been reduced to the sum of their parts-a heart, some kidneys, an intestine-each part with its own doctor.

From Portland, Oregon, I took my family to Greeley County, in the most sparsely populated area of Kansas. Our town of 800 had one grocery store (closes at 6:00 p.m., plan ahead!), one bank, one pharmacy/general store, a weekly newspaper, and an 18-bed hospital. I joined a group of four other family medicine physicians, and together we addressed the health care needs of people in a 2,700-square-mile section of our state. My family was welcomed and supported, my work was appreciated, and, as for my broad interests, well, let’s just say that I was never bored. I delivered babies and witnessed final breaths. I managed diabetes and set broken bones. I fished foreign bodies out of eyes…and some other places.

I did eventually move back to Portland, where I’m now helping to teach the next generation of family medicine physicians how to provide truly comprehensive, patient-centered care. The truth about the American health care system is that we don’t actually have a system. Dr. Welby faded into the background, mocked and underpaid, while the high-dollar proceduralists became what the public thinks of as “Doctor.” The most cost-effective, high-performing health care systems in the world rest on a strong foundation of family-oriented primary care, and it’s about time America returned to its roots and did the same.

Robyn Liu, MD, MPH, is an assistant professor of family medicine at Oregon Health & Science University and the New Physician member of the American Academy of Family Physicians Board of Directors.

*Photo courtesy of BluegrassAnnie.

The post What You City Docs Miss appeared first on Zócalo Public Square.