A Rural Remedy : Medivan Brings Doctor to Remote Back-Country Dwellers

The steady hum that echoes through this small, high desert town on the first Wednesday of each month signals the latest effort to improve health care in isolated rural areas of San Diego County.

It comes from the generator that powers the Medivan, a doctor’s office on wheels begun several months ago by El Cajon Valley Hospital to reach seniors, low-income adults and other residents who, because they choose to live in the county’s rural half, often go without regular medical treatment.

“It’s a fantastic deal for us,” said senior Harlan Hester, as he made his way into the converted mobile home for his monthly appointment with Dr. Bernard Michlin. “God, we’re 60 miles away from the nearest hospital.”

Marcy Bryant, a 25-year Jacumban whom Hester brought in for a blood-pressure check, said, “I haven’t had my blood checked in ages. It’s hard for us to see a doctor because many of us don’t drive.”

The van, which also visits Portrero and Alpine during its monthly rounds, joins the already established Mountain Health Center near Boulevard and the North County Health Services out of San Marcos, which cater to rural health needs. The nonprofit agencies cover their costs through government grants, contract services and individual fees.

“Most people don’t think of any part of San Diego County as rural, but the reality is that more than half of the county is defined as such, with high desert and national forests,” said Fred Jacobsen, director of Rural East County Mental Health Services.

“You have a high percentage of seniors, who have moved from urban areas because of lower land costs and rent and the dry air. And you have a certain percentage of low-income people, who also like the low costs and peaceful environment, and who tend to have a lot of children.”

Jacobsen, who ran a similar health agency in West Virginia, said the impetus for better health services in rural east county began in the mid-1970s with pressure from senior citizen groups. The Mountain Health Center was set up in 1974 as a primary health clinic, in conjunction with a government program to begin home visits to the rural infirm.

Rural northeast communities, from Valley Center to Santa Ysabel, also have a large group of the elderly, but they also contain significant numbers of migrant farm workers, the majority of whom are Hispanic. The northeast county area is honeycombed with citrus and avocado groves.

“I do think that migrant workers, especially those with families, now know there is medical care available,” said Dorothy Reno, who helped begin North County Health Services in 1971 as a tiny rural clinic and is now its executive director. It continues to serve migrants in the now-urbanizing North County communities of Encinitas, San Marcos and Ramona, while treating seniors in still-rural pockets east of Escondido.

In all cases, the emphasis is on reaching those people who might otherwise go without treatment until a dire emergency requires the use of an ambulance or a Life Flight helicopter. Except in towns like Julian and Ramona, no doctors practice regularly in the rural regions.

“These people have a strong self reliance and in many cases are very independent,” Jacobsen said. “Those characteristics are commendable but often result in not dealing with medical situations until a time of crisis.”

Jacobsen said that many rural residents have gone for years without having a need for a regular physician. Other residents, as they grow older, develop more chronic problems but find that they have outlived their doctors from the areas where they previously lived. As a result, doctors treating rural patients frequently find illnesses at more serious stages than for similar patients in cities.

Teriz Morel, the nurse practitioner at the Mountain Health Clinic, said that most seniors will “do just about anything” to avoid going to a nursing home, even when they need regular oxygen or medical checks for their diabetes or heart failure. For that reason, home visits by her and also by a nurse from the Medivan have proved popular.

“Some don’t have phones, many have old cars that barely run; they are living on a shoestring,” Morel said. “So they need to have someone checking after them.”

Transportation is a real problem for all age groups, Morel said. “If someone out here is living alone, or a single mother with children and on welfare, they can only get into town, like El Cajon, when money is available for gas. And since many have old cars that take $20 to fill the tank, they are not going to drive in for medical care until someone is very, very sick.”

Morel is joined by a doctor at the Mountain Health Clinic three days a week. In addition, the clinic has begun a prenatal program for mothers in the back country. Morel will check a mother’s progress through the first seven months according to protocols from a supervising pediatrician in Lemon Grove. The mothers will see the doctor directly during their last two months of pregnancy.

The isolation and independence of rural residents challenges the doctors and nurses at first because of the need to establish trust.

“Building that trust is the hardest thing of all to do,” said Nancy Stengel, the El Cajon Valley Hospital nurse who assists Michlin on the Medivan. Stengel did several surveys in East County to determine need before the van was sent out on a regular basis. Although the van itself does not turn a profit, El Cajon Valley believes it promotes a positive image for the hospital and directs residents to the hospital in case of emergencies or medical tests.

Michlin recently was approached by an elderly man who pedaled up on a bike to the town center, where the van was parked. The man had no appointment and no need for medical attention, he said, but simply wanted to “get a look” at the doctor.

“That’s what I meant,” Stengel said. “We’re pretty much on a first-name basis with the people in Jacumba now. In Portrero, we’re still working at it.”

Said Michlin: “At first, there was a tremendous amount of curiosity among these people, but now I see patients because people know we are conscientious and work hard.” In addition to his weekly stints on the van, Michlin has a regular practice in San Diego.

The issue of confidentiality between doctor and patient takes on added importance in rural treatment. In this word-of-mouth culture, neighbors tend to be curious about one another.

“For example, it makes things difficult when doing family planning,” said Thomas Brady, director of the Mountain Health Center, “such as when a young girl comes into the clinic and her neighbor is sitting there. We have to make very sure that the staff is aware of that.”

Jacobsen said that in the case of mental health counseling, he prefers to work at the patient’s home. “But since neighbors watch neighbors, we have to be very careful not to be too conspicuous.”

Although the county’s many Indian reservations have their own network of health clinics, financed by state and federal sources, Jacobsen’s mental health clinic covers both Indian and non-Indian patients.

“And many Indians prefer to come to our clinic rather than have us seen on the reservation,” he said.

North County Health Services has concentrated on preventive medicine in recent years, running programs in rural communities to teach people how to recognize disease warning signs and to follow beneficial exercise and diet regimens.

At present, the clinic has a project to spot heart disease risks among rural residents.

“We are working through churches and service clubs,” Shimon Camiel said. “We will gather a group of seniors together, run a health-risk appraisal of them and then try to get them to quit smoking, cut fats, exercise more and set up support groups to help each other continue the program.”

Camiel said that the notion of prevention has yet to catch on in a major way.

“Along the coast--like in Del Mar--you hear the vocabulary of professional prevention, such as aerobics, Jane Fonda workouts and the similar,” Camiel said. “Even that commercial message hasn’t penetrated inland all that far. Jane Fonda isn’t out there--just the cigar-smoking guy with a Doberman in the back of a pickup truck.”

The clinic also pairs medical students from UC San Diego with public health students at San Diego State University to visit rural areas and find out what problems exist.

“We’ve had students look at what emergency services are available in places such as Agape (near Warner Springs),” Camiel said. “They found that the quickest way to get to a hospital in an emergency was in the back of a beat-up van that belonged to a retired nurse.”