Taking Care of America : Towns Big and Small Feel Health-Care Pinch as Reservists Ship Out

They are still performing appendectomies in small-town America, and there are still enough outstretched arms to receive newborns in the delivery rooms. But now that thousands of doctors, nurses and hospital technicians have been siphoned off to the war in the Persian Gulf, some of the patients and co-workers they left behind have been feeling the strain.

More than 40,000 medical workers are serving in the Middle East, and thousands of others who have been called away from their civilian posts are serving at hospitals and clinics in Europe and the United States.

Although together they represent a relatively small percentage of the medical professionals nationwide, their absence has forced rural clinics and even some urban hospitals--which under normal circumstances face shortages of doctors and nurses--to schedule double shifts, to refer patients to out-of-town facilities and to simply make do.

So a young doctor in Eureka, Calif., is delivering twice as many babies in a month as she used to; a poverty clinic in rural North Carolina has so many patients that the doctors are working nights and days; nurses in several Veterans Administration hospitals are working longer shifts; and in Boston City Hospital, where four of the 12 senior surgeons in the trauma unit have been called up, a health official is worried that if more doctors go, “the quality of trauma services in the city of Boston will go down considerably.”

“Every time a doctor is yanked from one of our clinics, we figure it knocks 2,000 people out of health care,” said Dave Cavanaugh, spokesman for the National Assn. of Community Health Centers, a network of 600 community and migrant centers. In a survey of the clinics, the group found its centers had lost about 125, or 5%, of their doctors.

“It’s a federal irony,” Cavanaugh said of the clash between the needs of the military and the federally supported clinics. “Here you have two federal programs designed to meet the nation’s needs colliding because they depend on the same people.”

Although the medical workers’ absence has not created a national crisis yet, Cavanaugh warns that if more doctors are shipped out, the infirm in rural America will really begin to suffer.

The people of Harnett County, N.C., pop. 66,000, have already felt a squeeze on two fronts from the reduced medical staff, and Richard Covington, administrator of the county’s four public clinics, has been bracing himself for more bad news.

“We already have an infant mortality rate that is sky high,” Covington said. “If we lose more doctors, I don’t know if we can handle much more pressure on our community.”

And the pressure has been steadily building. One of the public clinics, just 10 miles north of Fort Bragg, has been serving twice as many patients since the base hospital staff was reduced and military families began swarming there for help.

At the same time, the poor people of Harnett County, a bucolic but impoverished area where Daniel Boone once trail-blazed, lost one doctor and a physician’s assistant. Just last week, Dr. Peter Clemens, one of the three doctors remaining in the county, received an inquiry from the Pentagon about his address and telephone number. Clemens finished his reserve duty, but the Pentagon is keeping in touch--just in case there is a need for more doctors.

“We have 165 ladies ready to give birth between now and May, and if we lose another doctor, well, I’m worried about those babies,” Covington said.

At the St. Francis Family Medical Center in Carlsbad, N.M., three doctors--one private and two paid by the National Health Service Corps--serve an indigent population of 25,000, treating about 70 patients a day. Now the private physician has been put on alert status for the naval reserves, and the other two may also be called up.

Seferino Montano, an administrator at the center, said if all the doctors go, the patients will be sent to the local private hospital. But he worried, “The people we treat don’t have medical insurance and couldn’t pay. In a lot of cases, hospitals refuse treatment. Even though they say they don’t, they do.”

The Army has established a committee to consider requests by reservists who feel they can’t leave. Of 57 requests, seven people, mostly doctors, have been allowed to stay home; 17 have been turned down; the rest are pending.

But people in all branches of the military pointed out that anybody--even highly sought-after professionals like doctors--who signed up to be in the reserves should have taken into consideration the hardship they might create if they had to leave.

“If you are truly essential to your community, you probably knew that before you signed up,” Army spokeswoman Virginia Stephanakis said.

The obligation is unequivocal. In the Navy, for example, reservists sign an agreement when they join up that says they are available for “immediate active duty in the event of war. . . . I am not engaged in any civilian occupation or pursuit, nor am I aware of any hardships or dependency situation which will result in a request from me, or from any other source, for cancellation of active-duty orders.”

So far, the Army has called up 2,000 of its 6,500 reservist doctors. Stephanakis said more may be activated if the casualty count begins mounting.

“We have already picked out a lot of the specialists we need, but we may need more,” she said.

Dr. Daniel H. Johnson, a New Orleans internist and officer in the American Medical Assn., said the military should probably consider the effect of a doctor leaving his home post--that it doesn’t just hurt his practice.

“There are all kinds of ripples in the community,” Johnson said. “Not only are the patients inconvenienced, but there’s a loss of income at the hospitals that depend on doctors to bring in business.”

But Johnson, who served in a MASH unit in Vietnam, made it clear he didn’t want to sound unpatriotic. “None of this is crying over spilt milk,” he said. “Of course, war means sacrifice. We all understand that.”

Pentagon officials in the Army, Air Force and Navy declined to divulge specific breakdowns of the number of doctors, dentists, nurses and technicians deployed in the United States and overseas for fear of giving the Iraqis even a hint at the number of casualties expected.

During the initial months of the military buildup in the Gulf last year, U.S. military hospitals had to quickly shift career military doctors and nurses to Saudi Arabia and then replace them at home bases.

When the Comfort, one of the Navy’s two hospital ships in the Gulf, shipped out with 1,000 military doctors, nurses and technicians--nearly the entire staff of the National Navy Medical Center in Bethesda, Md.--aboard, only 450 reservists were sent in to fill in. At first the center closed down 75 of its 350 beds, but more doctors were sent in and the center is now up to full speed.

But replacing the career military doctors at military bases hasn’t been easy. A few in the South still haven’t been able to replace specialists such as radiologists and nurses who work in surgery units. And because many reservists also hold government jobs, their deployment has reduced the staff at Veterans Administration hospitals by about 2%.

Donna St. John, a VA spokeswoman, said the hospitals haven’t felt the crunch quite yet. “They’ve hired temporary staff, and some nurses are working overtime,” she said. “So far we’re OK.”

Since her partner went off to serve at a base hospital in Texas, obstetrician Kim Ervin of Eureka, Calif., has been so busy juggling deliveries of babies that she has had to turn away patients. On the average, she is delivering 30 babies a month compared to the nationwide average of 13.

“Everybody is overburdened,” she said of the other two doctors practicing in the rural area of 140,000. She said her patients complained when her partner disappeared.

“They felt it wasn’t fair,” Ervin said. “It puts a lot of stress on me, and they worry that I might not do very well. . . . I can’t be available to them every hour of the day, seven days a week, without losing my own sanity.”

Some people have even put off medical care because they fear a new doctor.

One couple in their 80s in Verdigre, Neb., were longtime patients of Dr. Ken Pavlik, who has been in Saudi Arabia since late December. Pavlik is the type of family practitioner who would drive five miles outside the farming town to give them a shot or some pills. This time, however, when the 84-year-old man became ill--vomiting off and on for 24 hours--he delayed calling Dr. D. J. Nagengast in nearby Bloomfield, who has been overseeing Pavlik’s practice.

“He was quite ill, but they hated to call a strange doctor,” says Nagengast, who sent the man to the local hospital, where he was found to have an intestinal flu.

“People are putting off seeking medical care,” he added. “They’ll wait until Monday morning to see how they feel. Sometimes they get better, and sometimes they get sicker.”

Nagengast now works seven days a week, serving his community of 1,600 people and the largely elderly community of 617 in Verdigre, including the 70 residents in the Alpine Village Nursing Home.

Pavlik also used to visit the nursing home five days a week, and the patients there counted on him. Nagengast can only make it on Sundays, and “there is a sort of triage” of the sick so that only the serious cases see the doctor, said Pat McElhose, the home’s administrator.

McElhose said there is apprehension among the patients.

“A lot of them have precarious health,” she said. “They wonder, ‘Will the care be there if I really need it in a crunch?’ ” But the farm population, of Czech stock, is stubborn and tough, she said.

“The fact that we’re at war makes a big, big difference,” she said. “They’re ready to make the sacrifice. They’re a very patriotic bunch.”

Baum reported from Washington and Venant reported from Los Angeles.