Health Horizons : MEDICINE : Rural Medical Delivery : Lack of a general hospital, shortage of doctors makes it difficult for the poor in redwood country to receive adequate care. One physician goes on the road to treat people.
Dr. Wendy Ring spends her days towing a mobile medical clinic around the countryside caring for people marooned in places that doctors don’t serve. If she weren’t doing that, she would probably be working in an inner-city clinic or treating the sick in some developing country.
Ring’s passion is to help people who have little but who need much. Her patients are the homeless who wander the streets of Eureka in California’s redwood country and the very young and the very old who live in once-thriving logging communities now drawn into a deep economic recession.
Once Eureka was the busy center of the state’s vast timber industry. But today logging is in sharp decline and the economy depends heavily on the thousands of tourists who flock to the North Coast country to hike, fish, hunt and enjoy the natural splendor of the sea and mountain scenery.
But for many of the 150,000 residents of Humboldt and neighboring Del Norte County, life is not so joyful. The forests are quiet. The stream of logging trucks that once flowed along mountain roads has slowed to a trickle. The men and women who worked the woods and the mills still remain, but most of them are out of work, out of money and out of health insurance. According to one estimate, only 20% of the local population has health insurance. Most of the rest are on government programs for the poor and the elderly or have no coverage of any kind.
Like the poor in hundreds of sparsely populated regions across the United States, the poor who live in California’s rural counties have extra burdens obtaining medical care, which some experts see as exceeding those faced by the poor who live in cities.
Living 50 miles from the nearest doctor without a car means there are lots of reasons for delaying health care, especially when there is no public transportation.
But perhaps more important are two factors unique to rural areas: the frequent absence of a county hospital--traditionally the last resort for the poverty-stricken and the uninsured--and, compared to cities, the relative shortage of physicians. Recent U.S. statistics show there are 97 physicians per 100,000 rural residents versus 225 physicians per 100,000 in urban areas.
Rural Americans, especially rural poor Americans, are more likely than people in cities to have difficulty finding health care services, reports the Center for Budget and Policy Priorities, a Washington-based independent organization that specializes in policy issues affecting low- and moderate-income people.
The poor in Humboldt and Del Norte, as well as other rural California counties, seem to fit the national pattern outlined in this and similar reports: fewer doctors, less health insurance, poorer health and fewer visits to a doctor than by their urban counterparts.
Nearly all of the 250 physicians in Humboldt and Del Norte counties practice in four cities: Eureka, Arcata, Crescent City and Fortuna. For the residents of numerous other communities, the only choice is to travel as much as 150 miles to get to a doctor and home again.
For the uninsured and those on Medi-Cal, the government medical program for the poor, a major problem is finding a doctor who will accept Medi-Cal payments, which are much less than most physicians’ charges.
When Wendy Ring arrived in Eureka three years ago, only a handful of the physicians who practice general medicine accepted Medi-Cal patients and most of them would take only a limited number. As the recession has deepened, the situation worsened, despite numerous recruitment drives conducted by overworked local doctors. Both counties are on the federal government list of medical manpower shortage areas.
Obtaining a specialist’s care in Eureka for her patients is a lot easier than finding a generalist to see a Medi-Cal or uninsured person, Ring says. This may be because specialists are more numerous than generalists in the city and consequently not as fearful of being swamped with patients who don’t have private insurance. In rural areas, specialists and generalists alike are hard to find.
The problem is evident in Crescent City. “If you include the emergency room physicians, there are only 10 to 12 primary-care doctors for a population of 30,000 to 35,000 spread over an area that covers from 25 miles north of here to 25 miles south,” says Dr. Michael Mavris, a Crescent City family practitioner and a member of the board of the county’s only hospital. “On some weekends, I’m the only doc to take care of everything.
“Sometimes I wish we had another pediatrician, a urologist, an ear and throat specialist, another orthopedist, and it would be nice to have a psychiatrist. There’s a need for them all.”
Mavris says he “has more patients than I can take care of.” He has not taken new patients--either private or Medi-Cal--for three years.
Attracting more primary-care physicians has long been a problem, according to doctors in both counties. Ironically, the North Coast region offers doctors the kinds of non-financial enticements many seek: outdoor recreation, scenic splendor, no traffic, fresh air and tranquillity.
But the pressure of a large number of residents on Medi-Cal seeking care, isolation from their peers and unhappy spouses who would be bored by small-town living tend to scare off the newcomers, says Dr. Phillip Wagner, a family practitioner in Eureka.
Young primary-care doctors fresh out of medical school generally avoid going to places like the North Coast because they are deep in debt and look for places where there is a steady income, Wagner says.
“Going to a rural area where there is no guarantee of income or regularity of work is frightening for them,” Wagner said. “They are more prone to join a group in a city or a health maintenance organization where their salary is guaranteed and worries removed.”
Most doctors already established in the area say they would be willing to accept their share of Medi-Cal and uninsured patients if they could be sure that their practice would not be overwhelmed by the needy. But the severe shortage of primary-care doctors combined with an exceptionally large number of patients with neither funds nor insurance cause most to bar their doors.
“I feel uncomfortable placing all the blame on doctors,” says Herman Spetzler, director of the Open Door Community Health Center, a nonprofit facility in Arcata. “Much of it is due to the Medi-Cal bureaucracy. It’s not easy to be a Medi-Cal provider.”
Ideally, he said, the problem could be solved if each doctor did 5% to 10% of his practice on Medi-Cal, but the complex Medi-Cal billing system requires a specially trained office staff for doctors to be able to receive payment.
Spetzler, whose clinic accepts Medi-Cal and low-income uninsured working people, explained that one-third to one-half of a doctor’s practice must be on Medi-Cal in order to make the special staff worthwhile. Because most doctors don’t want that large of a Medi-Cal load, a few doctors do 5% or 10% of their practice free rather than do Medi-Cal book work, and the rest avoid the program.
Before another Open Door Clinic opened recently in Crescent City, many residents on Medi-Cal drove the 150 miles round trip to Arcata to see a doctor.
Another disincentive for doctors is having to deal with patients with mental health problems, especially among the growing number of homeless in the area, he said. Nevertheless, Spetzler sees some hope for the future.
“Many doctors are ill-equipped to deal with the large number of indigents with psychological problems,” Spetzler said. “But I believe younger doctors are coming out with a different consciousness and are choosing to deal with things like primary health care and homelessness. The private sector has not been trying to attract this type of doctor. They want doctors whose interests are different.”
Wendy Ring’s dedication to serving the poor, despite the economic hardship it entails, is cause for both acclaim from the community and criticism from some of her peers. She has a ready answer when asked why she prefers caring for poor people.
“Because of who I am,” she replies. “Financial success is not my priority. I feel it’s important for people to share what they have. Medical skills are what I have and they must be used responsibly. They are not private property.”
Ring feels strongly the need to fill the vacuum of primary care for the uninsured and those on Medi-Cal.
“The heyday of the timber industry is over,” she says. “People are getting poorer and they will get even more poor. There are high rates of alcoholism, drug abuse and family violence and there are not the resources to deal with them.”
Ring already had a history of working for causes before arriving on the North Coast. A 1983 graduate of Columbia University College of Physicians and Surgeons, she had spent the previous seven years working with the homeless in Albuquerque, running a clinic for Navajo Indians in New Mexico and treating the sick in Nicaragua.
In California, the young general practitioner from Boston was determined to find a way to get care to the rural poor. She spent $10,000----some of it contributed by a church and by local doctors----for an old pickup truck, a 1968 trailer and some medical equipment and renovated the trailer into a medical clinic on wheels. Inside the trailer she has an examining room, a lab to do blood analysis, a supply of drug samples and a small office.
Pulling the trailer behind, Ring drives her 1979 Ford pickup 300 miles a week tending the medical needs of the homeless in Eureka’s Old Town and patients in Klamath--65 miles north of Eureka--and Rio Del, a mill town 25 miles south of of the city.
As Ring sees it, she and the patients have a partnership in which the responsibilities are shared: She provides the care and the small communities provide an advisory committee; volunteers to do office work and publicity to let the surrounding residents know that she is available.
“I earn a lot less than most docs but the overhead is low,” Ring says, laughing. “At first, I made some (medical) people defensive and, as a consequence, I’ve had to earn a lot of respect from the medical community. There is a medical bias that if you work with the poor you must not be a good doctor.
“I’ve joined the medical society to show them I am just like them except that I work out of a trailer. Now I feel the feeling is changing. My colleagues are much warmer.” Ninety-five percent of Ring’s current patients are on Medi-Cal or have no coverage of any kind, she says. The medical complaints of most are routine--colds, earaches, sick babies and elderly diabetics or victims of other chronic illnesses who require periodic checkups.
While many of the local doctors admire her dedication and drive, they feel that her idealism is offset by the hard world of political and economic realities. Many believe that aside from not being cost-effective, a mobile clinic that arrives only periodically leaves people unserved too often.
There are also non-medical reasons for opposing Ring’s operation. Recently, for example, a church in Fortuna, a relatively prosperous town 15 miles south of Eureka, offered to host her program to take care of local patients on Medi-Cal. As of last summer, no primary-care doctor in Fortuna was accepting Medi-Cal patients.
The local doctors objected to the plan because it meant that if one of Ring’s patients needed hospitalization they would have to provide care in the hospital. Ring had declined to obtain hospital privileges on grounds that she would be obliged to work near the hospital and give up seeing patients in the other communities that had no doctors at all.
The matter was resolved by the city manager, who Ring says refused to put the matter before the city council and used a zoning ordinance to keep out her mobile clinic.
The real reason for turning her down, she suspects, is that the local hospital was planning to become certified for a new government program for medically underserved counties that enables medical providers to obtain fees for Medi-Cal patients that are substantially higher than what Medi-Cal usually pays.
Recently Ring herself became certified by the government program and plans to expand her services, especially in mental health, where she hopes to hire several therapists. She has a new trailer now and hopes one day to replace the 1979 pickup.
“I know we’re making a difference in the lives of the people we care for,” she says. “I’m happy. You do what you can.”
Children in Four California Counties: Del Norte, Humboldt, Shasta and Trinity Counties
Compared to urban areas, a larger percentage of children in these rural counties are born into poverty and a larger percentage die during the first year of life.
INFANT MORTALITY
Percentage of babies who die in their first year of life per 1,000 live births. 1988 Calif. rate: 8.6 1988 U.S. rate: 10.0
COUNTY 1985 1986 1987 1988 Del Norte 12.5% 13.9% 17.4% 14.6% Humboldt 14.7 6.9 9.0 17.6 Shasta 10.5 10.2 14.6 11.0 Trinity 6.0 13.8 6.0 6.6
CHILDREN LIVING IN EXTREME POVERTY
Percentage of children whose families are so poor (income less than $8,328 annually for a family of three) that they receive Aid to Families with Dependent Children. 1990 Calif. rate: 17% 1990 U.S. rate: 12%
COUNTY 1987 1988 1989 1990 Del Norte 33% 37% 32% 28% Humboldt 23 23 24 23 Shasta 25 25 25 25 Trinity 20 19 19 19
Source: Children Now, Santa Monica
Contraception by Country
Percent of couples using contraception in countries with an average family size of two children or fewer:
COUNTRY USING CONTRACEPTION IN 1990 % OF COUPLES* Czechoslovakia 95% United Kingdom 83% Belgium 81% Finland 80% France 79% West Germany 78% Italy 78% Sweden 78% Taiwan 78% Bulgaria 77% South Korea 77% United States 76% Singapore 74% Canada 73% Hungary 73% Hong Kong 72% Netherlands 72% Austria 71% Norway 71% Switzerland 71%
* The contraceptive prevalence rates used in this study are the latest available estimates of the proportion of reproductive-age women (15 to 49) who are married or living in union and who are using any method of family planning, excluding abortion, but including less effective methods.
Source: Population Crisis Committee, Washington, D.C.
