FIREBAUGH, Calif. — On a morning in early January, the air is cold and Firebaugh's main street is nearly empty. But the Sablan Medical Clinic is quickly filling up with people eager to see the physicians they affectionately call Dr. Marcia and Dr. Oscar.
Lela Burkhart, whose family owns a farm in this remote San Joaquin Valley town surrounded by fields of pistachios and almonds, is one of the first patients of the day.
Burkhart, 86, recently had heart surgery, and this morning she's feeling tired and short of breath. Oscar Sablan tells her that the lab tests show she is dangerously anemic.
"You are bleeding inside, even though you cannot see it," he tells her.
"Do I need to go to the hospital?" she asks.
Sablan nods. "It's a little too low for us to wait," he says, patting her on the back.
Thirty years ago, Oscar and his wife, Marcia, made a plan: work in a rural area for three years and walk away without any medical school debt. So they moved from tropical Hawaii to dusty Firebaugh and started a practice in a trailer on the corner of O and 9th streets. They didn't intend to stay.
They are still here, the only full-time doctors in town, treating many of the same families as when they arrived. The couple raised four children in Firebaugh and grew so committed to the town that she served as mayor and he as school board president.
"This became our home," Oscar Sablan says. "I still can't believe it."
After her consultations with the doctor she's known for decades, Burkhart says she will head to the hospital.
She is painfully aware of how far away it is. Twenty years ago, her 42-year-old son believed he was having an asthma attack. Oscar Sablan recognized his symptoms as a heart attack and had him airlifted to a hospital in Madera. But his heart stopped on the way. Sablan says he believes that if they had lived closer to a trauma center, he might have survived.
Sablan promises to check on her once she is admitted. Then he starts making calls to Fresno, nearly 45 miles away. First, the heart doctor. Then a gastroenterologist. Then the emergency room doctor. Each time, he explains his patient's health situation and advises them that she is on her way in.
"I feel uncomfortable treating her as an outpatient," Sablan says to the emergency room doctor. "I'm not that brave … even out here in the country."
Burkhart says the whole town, from wealthy ranchers to migrant farmworkers, relies on the Sablans.
"They've taken care of all our families," she says. "I don't know what we'd do without them here."
But now Oscar is 61 and Maria is 65, and they realize they can't do this forever. They're beginning to plan their retirement, looking forward to giving up their 65-hour workweek and spending more time traveling and visiting with their eight grandchildren. But they're worried about what will happen to their patients.
"These are people we have guided through bypass surgeries, pneumonias, accidents and injuries, cancers," he says. "But it is something we are going to have to do, now or later."
Much of inland California is made up of towns just like Firebaugh, where large swaths of the population are uninsured, where traveling to a hospital means a long drive, and where doctors and pharmacists are in short supply. The nearest hospital to Firebaugh is 20 miles away, and the closest trauma center is nearly 40.
The federal health reform law is designed to help improve healthcare in rural areas by expanding access to coverage and investing in primary care doctors and rural hospitals. But that is an uphill battle in places like the San Joaquin Valley, says Marlene Bengiamin, research director at the Central Valley Health Policy Institute.
In a recent study, the institute found that the valley failed to meet any of 10 national standards in such areas as reducing smoking, reducing the number of deaths from car crashes and improving access to healthcare.
"We fail miserably," she says. "There are so many health challenges in the valley."
The Sablans know those challenges better than most. They've treated gunshot wounds, set broken bones and resuscitated heart attack victims. They've also cared for farmworkers exposed to pesticides and injured in agricultural accidents.
The clinic, now in a single-story white building with a blue awning, sits next to a community college and across the street from a discount store. In the bright, airy waiting room, a television airs a consistent stream of health messages. A few patients read newspapers in Spanish, and children play in a gigantic pastel playhouse.
Jasmin Barrera has brought her 17-month-old daughter, Kayleen Rodriguez, in for an exam. Kayleen was born premature and has severe asthma. In the last few days, she's been coughing more than normal.
"Let's get her up here and take a look at her," Marcia Sablan says, carefully unzipping the girl's pink jacket and holding the stethoscope to her chest. The girl whimpers and wheezes, and grabs at the stethoscope.
"She still has a lot of phlegm in her chest," Sablan says, explaining to Barrera that she'll prescribe an antibiotic for the girl.
Barrera smiles at Kayleen and pretends to make her nose disappear. The girl giggles.
The Sablans' journey to rural California began at Saint Louis University in Missouri. He was the oldest of 13 from Saipan, a U.S. commonwealth in the Pacific. She was a St. Louis native and a former Peace Corps volunteer. They met in biology class and got married a few years later.
They moved to Hawaii for medical school, with one child in tow. Once there, they had three more. When they learned about the National Health Service Corps, a federal program that would pay their medical debt, they jumped at the chance. So they brought their children to California in 1981. They bought a house sight unseen, which they still live in today.
Firebaugh, one of the oldest towns in the area, was created in the 1800s as a trading post and ferry crossing for gold prospectors. Now, the predominantly Latino city has about 7,500 residents, and the median income is about $33,000. Roughly 28% of families live below the poverty level.
Since the beginning, the Sablans have worked round the clock, staying open in the evenings and on Saturdays and often making house calls. Nevertheless, patients showed up on their doorstep for care. "We had to train our patients not to come to our house," Oscar Sablan says.
Their eldest son, Tony Sablan, says he remembers patients knocking on the front door night and day. "It was our norm," he says. His parents also ran into their patients everywhere they went. Going to the grocery store could take all afternoon, he says, so sometimes he and his siblings did the shopping instead.
The couple grew attached to Firebaugh. Their patients became their friends, and their friends became their patients.
But as they built up their medical practice, the Sablans say, they realized that they could do only so much in the exam room. For example, they would tell their diabetic patients to exercise, but there were few places to do so. So they turned to politics. "I just saw that was the only way change could be made," says Marcia Sablan, who is still on the City Council.
During her time in city government, Sablan has helped get more affordable housing, parks and a walking path in the city. She also spearheaded the opening of a child-care center. Her husband, who is also still on the school board, helped get sidewalks built near the schools so students could walk to campus.
"What I do there is just as important but more far-reaching in terms of health outcomes," he says, "than what I do taking care of the day-to-day patients."
Oscar Sablan, who laughs easily and talks with his hands, says his passion for medicine comes from the science. He frequently pulls out medical books to teach patients about their disease. Marcia, a motherly figure who has a high voice and towers over most of her patients, draws her inspiration from the people she cares for. She knows all about their families, jobs and hobbies and often spends a few minutes chatting with each one.
Both are well-dressed and energetic, though their faces betray their exhaustion. Throughout the workday, the couple does a well-rehearsed dance, switching patients, asking each other for medical advice and jointly diagnosing.
A few years ago, when the Sablans starting talking about retirement, they tried unsuccessfully to recruit doctors to take their place. The uncertainty and long hours of private practice frightened newer doctors away, Oscar Sablan says. "The younger people don't want to be on call," he says. "They really want an 8-to-5 job."
Last year, the Sablans took another step toward retirement by selling their practice — now up to 13,000 patients — to a health clinic, Valley Health Team, and becoming salaried employees. The transition has been difficult. "When you have to give it up, you leave a little of yourself," Oscar Sablan says. "It's not like selling a car."
On a recent afternoon, Sonia Rodriguez brings her daughter to the office for a checkup. Rodriguez says that four generations of her family go to the Sablans for care, ever since a near tragedy more than 20 years ago brought them together.
That Saturday afternoon, Marcia Sablan was working on medical charts when she heard a scream. She rushed outside to see a woman running across the street, holding a limp infant girl who had fallen into a toilet and wasn't breathing. Sablan did CPR, and the girl started breathing again.
"Marcia saved my sister's life," Rodriguez, 28, says. Her sister, now 23 and in the Army, became Sablan's goddaughter.
Rodriguez says she looks forward to the fifth generation coming to the same doctor's office.
Sablan frowns. "You know, Oscar has been talking about retiring," she says.
Rodriguez shakes her head and says Sablan can never retire. After all, she and Oscar are the only doctors the family — and much of Firebaugh — has ever known.