CALIFORNIA ALBUM : Calamities of a War on Drugs : For 20 years, Dr. Amalia Katsigeanis has led Imperial Valley Methadone Clinic in a lonely battle against heroin. But critics are crying for change, citing lax management of books and funds.

When she was growing up in the Imperial Valley, Sandra Martinez was surrounded by heroin.

“Other places have marijuana and crack, but in the Imperial Valley, the drug of choice is heroin,” Martinez said. “You grow up watching your friends use it, and then one day you’re ‘fixing’ too.”

At 34, Martinez has suffered the downward spiral common to heroin addicts: She wasted away to 87 pounds, was a thief and a prostitute and went to prison.

Now Martinez is struggling to get her life together. She has gotten custody of her three children and has a part-time job. And every morning she goes to a nondescript building in a commercial part of this border town to receive a legal dose of methadone, a synthetic opiate that dulls the craving for heroin.

“Without this clinic, I’d probably slip back into ‘the life’ very quickly,” she said. “We all would.”

For 20 years the Imperial Valley Methadone Clinic, run by a nonprofit group and kept afloat by state and federal money, has been the only methadone clinic for heroin users in impoverished Imperial County, despite the fact that the county is thought by drug experts to have more heroin addicts per capita than some urban areas.

But now the clinic is imperiled because of its lengthy history of lax management, bad record-keeping and lack of financial accountability.

The clinic’s board of directors, including longtime director Sheriff Oren R. Fox, resigned in protest of the clinic’s poor management. The Imperial County Board of Supervisors, annoyed at the prospect of being stuck with the clinic’s bad debts, has withdrawn support.

Three different agencies of the state government have written critical evaluations of the seemingly haphazard way the clinic is run. Clinic officials have been warned that its license may be revoked unless long overdue changes are made.

At the center of the controversy is the clinic’s founder and executive director, Dr. Amalia Katsigeanis, a 69-year-old surgeon and general practitioner who is widely acclaimed for her four decades of work with the poor and addicted of Imperial County but is also known for her disdain for paperwork and health system bureaucrats.

Katsigeanis serves on the Calexico City Council, keeps a private practice of mostly poor patients, is active in the fight to keep Calexico Hospital open and, until recently, was a doctor at Centinela State Prison. She ran unsuccessfully last year for county supervisor.

Katsigeanis acknowledges that the clinic’s books and paperwork have not been tidy. She also concedes that she has spread herself thin and has not spent enough time at the clinic to ensure that records are up to date and that patients get counseling along with their daily swig of the clear, bitter-tasting liquid.

But she maintains that the clinic may be reaping a backlash from her many fights with the Imperial County medical Establishment over what she sees as its lack of concern for the poor.

“This clinic has been a thorn in their side,” she said. “So when these things occurred--the financial shortfalls, the audit problems--they said, ‘The hell with you. We don’t want you around here anymore.’ The state immediately picked up on that.

“But if they close the doors--which I will never allow to happen--they are going to have a big problem with the heroin users.”

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The addicts start arriving at the clinic before the doors open at 6 a.m., seven days a week.

They come from Calexico, El Centro, Brawley (the valley’s historic hot spot for heroin) and Holtville. A few come from Mexicali and Yuma. Some car-pool.

The main reason given for the Imperial Valley’s plague of heroin is its proximity to heroin manufacturing sites in Sinaloa. Also, heroin is a relatively inexpensive drug.

Because of its ferociously addictive nature, heroin is said by drug specialists to flourish among people trapped in poverty and despair. County health and law enforcement officials put the number of active addicts in Imperial County at about 1,500; add occasional “tappers” and the number swells upward of 2,500.

With addicts needing to feed a daily habit, heroin contributes significantly to the valley’s crime problems. Imperial County (population 137,500) has one of the highest burglary rates in the state.

Most of the clinic’s patients have been in prison. Many fear that if they cannot get methadone and are drawn back into heroin, their next prison stretch will be for life under the state’s new get-tough attitude toward criminals.

“I’m 45, and if I go in (prison) again, I’ll never get out,” said John Guillen of Brawley. “That’s what methadone does for me; keeps me out of prison.”

When the methadone movement began in the 1970s, health officials hoped that it would help addicts move from heroin to drug-free lives. Those hopes proved overly optimistic, and it is now clear that only a small fraction of methadone users can get completely detoxified.

“I am disappointed that methadone has not done what it originally meant to do--that is wean these users away from drugs,” said Fox, recently elected to a fifth term. “(But) until medical science comes up with something else, methadone is all we have. . . .”

The critics of methadone say it only substitutes one kind of addiction for another, and there is some truth to the argument.

Methadone can be physically and psychologically addictive, although far less than heroin. It is also cheaper than heroin, less debilitating and needs to be taken only once a day, whereas heroin addicts need a fix every four hours.

Another advantage for methadone, its supporters say, is that it is taken orally. Heroin is injected, and the sharing of needles among addicts spreads AIDS, hepatitis and other diseases.

“With methadone, you don’t have to be in the streets, hustling all day for a fix,” said Mark Rivera, 32, a fieldworker from Brawley. “We come here in the morning and then we’ve got the rest of the day to do something useful.”

With heroin addicts, life is a one day at a time process. In the Imperial Valley, those days have begun with a trip to the threadbare clinic on Cesar Chavez Boulevard.

Now, added to the uncertainty of whether they can resist the deadly lure of heroin is the uncertainty over the clinic’s future.

“We’re all up in the air,” Martinez said. “We’re living on hope.”

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Unlike other county governments in California, the Imperial County government has never allocated any of its own money to methadone.

For one thing, the county government is chronically short of money. For another, county officials prefer the “cold turkey” approach to drug addiction rather than the “maintenance” approach used in methadone clinics.

California now has 222 methadone clinics serving 30,000 addicts in maintenance programs. A handful of the clinics are run by county health departments; the rest are run either by nonprofit groups or as profitable ventures by private chains, all under strict regulation by the state.

Half the Calexico clinic’s 127 patients get their daily doses free through Medi-Cal. Those who do not qualify for Medi-Cal as disabled or indigent must pay their own way.

In an effort to keep costs for clients down, until the middle of last year the clinic was charging $4.17 a day to private patients, significantly below what it billed Medi-Cal for that program’s patients.

State auditors discovered this discrepancy--which runs counter to a law prohibiting clinics from billing Medi-Cal at a higher rate than private patients--and are demanding that the county government, which has acted as a co-signer for the clinic’s state license, repay the state $72,000 for 1991-92. The state is auditing other years, which will probably lead to additional repayment demands.

Other auditors found that clinic staff did not promptly record the results of patients’ blood tests for AIDS and venereal disease.

In the past, the clinic has also run afoul of the IRS for not withholding taxes from the clinic’s seven employees. Katsigeanis has also had personal problems with the IRS over back taxes and is now on a repayment schedule.

“We are poor and we’ve run in the red several years,” Katsigeanis said. “But we have done the best we could, and except for us, there is no alternative. We are the only program the county has for heroin users and that sucks.”

To equalize the cost between Medi-Cal patients and private patients, the clinic has raised prices to $9 a day. Katsigeanis worries that this could scare away some patients or force them to resort to crime to pay for methadone.

Even officials who admire Katsigeanis say they have begun to lose patience with her idiosyncratic way of running the clinic.

“I have a soft spot in my heart for her,” said Sheriff Fox. “She spent thousands and thousands of her own money. She did the entire Imperial Valley a service in pulling the clinic together and keeping it running all these years, when a lot of people would have given up.”

Still, Fox said, “Maybe the county or the state or some private operator would be better.”

The same sentiment is expressed by Rudy G. Lopez, the county’s mental health director: “I would not have a problem if someone else wanted to run a methadone program in this county.”

Although a private chain has offered to step in if Katsigeanis falters, getting that chain to follow through might prove difficult.

Calexico Hospital, facing similar problems, has hired outside consultants, management firms and directors, only to see them flee because of the valley’s brutal summer heat, constant political bickering and intractable economic problems, including an unemployment rate of about 30%.

Joy Jarfors, manager of the methadone licensing branch for the state Department of Alcohol and Drug Programs, said the department has long been concerned about the clinic but has been reluctant to crack down because of Katsigeanis.

“She’s like Mother Theresa,” Jarfors said. “She’s been working with the poorest of the poor . . . holding down six jobs because no one else would do them.

“She’s like a missionary, but there comes a time when you just have to straighten up and follow the rules.”