SALUD CLINIC: A History and Memoir

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In 1967, at the suggestion of Herbert Bauer, head of Yolo County Public Health, I began to develop migrant worker free clinics in Yolo County.  He provided a list of some 400 migrant housing sites. The clinics  were held at night, and provided basic free medical care, especially effective for children who had many easily treatable problems, like parasitosis, anemia, silent tuberculosis, and  chronic  vision, dental or ear disease. For 8 years I had been active in the local medical community, and medical society; the public generally approved of the clinics, and many physicians volunteered.

In time the UCD School of Medicine appeared at the Davis campus; I proposed  a very substantial Federal  grant application,  based on a strong local history and   support. It was approved, however unfortunately, the new medical school  immediately began to  mismanage the project,   and very quickly lost the funding; perhaps migrant farm workers were not the fledgling school’s  primary concern,  which was to build a medical school from scratch. Furthermore, technology already had  changed agriculture so much and so fast that migrant workers, once numbering more than 10,000 each season, no longer were needed; chemicals and machines replaced them.

Brooks Smith,  and I were  the original physician instructors for the UCD Family Nurse Practioner (FNP) progam established by the  U C Davis Department of Family Practice. We hoped that FNPs  would serve small towns like Yolo, Knights Landing and Esparto,  which  had long tried to attract and retain physicians, but repeatedly  failed.  We felt  that well trained FNPs could provide care under the supervision of a licensed physician who did not need to always be on site. I had encouraged some  small rural Yolo County towns to build, own, and operate their own clinics, staffed by FNPs  in what became the Salud Model.

After Federal  (HEW) support  for the Migrant Health Project was withdrawn, there remained a lack of accesible health care in small rural towns, with a related  political urgency to  respond to  the health needs, or demands,  of many permanent resident Spanish speakers.  Accordingly, the Migrant Health Project was rolled over and renamed Regional Rural Health.  The idea was to address both those needs by forming a Board of Directors predominantly made up of  Spanish speaking immigrants, to develop and operte rural clinics.  The general  followed the Salud Model.

In the Summer of 1968  John Siden, director for the Broderick Christian Center in Eastern Yolo County, asked me to speak about a medical  clinic there.   Broderick  was  an older unincorporated town like  the adjacent port and industrial community of West Sacramento,  where the relatively more rich and famous lived; nearby  Bryte, the smallest,  oldest and most stable town in the area, was  home to many East European immigrants, notably those from Russia and the Ukraine. There were other poor ethnic and borderline poor socio economic people, including Spanish speakers, and marginally homeless of all ages and races.

I’m told the word Yolo meant swamp in an indigenous language, and implies mosquitoes. The older streets of Broderick and Bryte… like old midtown Sacramento,  are lined with  typical 1 3/4 story buildings, where the lower levels rise only about seven feet above ground, and the main building is reached by 3/4 story front steps. They had been built that way in expectation of winter flooding, so common one hundred years ago. In

1850 was a very bad year for  Sacramento Valley health– trappers enroute to Sacramento from Oregon reported that the only above ground valley land were the Sutter Buttes, thrusting up from an inland fresh water sea.   The trappers brought malaria with them, which decimated native americans, while a  cholera epidemic came up river  with gold miners from the bay area, decimating Sacramentans.  As flood control became more effective old  low-ceiling  ground floor spaces have often been made into living quarters; that is true of the building at 5th and C streets that became the  original Salud Clinic.

East Yolo, as the area was called, was not  far in distance, but a half century  in time away from the Yolo County administrative centers in Woodland, where the low cost or free medical care was available at the Yolo General Hospital; and a century away from priveleged academic Davis and the students there.  Across the Sacramento River were the State Capitol, the Sacramento County Hospital and clinics, but medical care was not readily available there to uninsured Yolo county residents.

People survived in an economic, and political backwater even though Yolo County maintained both a Dept of Public Health office, and a  sheriff’s substation at at the West end of the I Street Bridge.  Such was the self effacing humility of residents that the bridgd was named for a Sacramento street. While  the clinic in Broderick was being built, volunteers from Davis and Woodland brought their own gallon jugs of bottled water because the local water was so unreliable, brackish and ill tasting.

With the completion of the cross country Lincoln Highway in 1916, travel had boomed.  The auto court was the way people settled for the night.  But when motels and better highways appeared, many large tree shaded courts became  trailer parks, and especially in Broderick,  were converted into  small houses for single men creating  clusters of ten by ten wooden shanties with shared baths. They had no indoor plumbing and very limited cooking facilities. Ongoing attempts to condemn these tiny units usually failed as they were often owned by politically powerful people; they survived until well after  incorporation of the city in 1988 [1]. These people, often could be called ‘bums’; indeed they were single men who lived a marginal itinerant but independent lives.  Many became active physical and emotional supporters of the  proposed Clinic.

Building Salud:

The events and timeline, beginning in 1969-70,  are taken from public documents, board minutes, and personal records. In October 1970, The Broderick Bryte Neighborhood Council invited me to discuss the Salud concept for small community clinics, emphasizing local control, ownership, and a determination to remain  relatively independent, under control of a local Board of Directors.  They adopted a comprehensive plan for the Salud East Yolo Medical Facility.

Paul Gutierrez  and Siden introduced me to Broderick. Paul was disillusioned with the politics of the Economic Opportunity Council, although he told me nothing of the details, and apparently the feeling was mutual.  He  and Jess Perez gathered some 4000 signatures in support of a clinic.  They  wanted to open a food service for the poorer residents in the area and call it Paul’s  Kitchen; they hoped to organize the community support for a health care facility generally along the Salud model.  The Broderick Christian Center, became the physical and animic source of energy during the orgainization and building of the clinic.  The Center  was meeting place, and eating place for people working on the clinic. Paul Hom, a lawyer, and also a UC Davis medical student, estabished a non  profit status for the clinic,  to promote donations of  money and of medical equipment,  like  the XRay.  Mike Kolar, and other UC Davis undergaduate students  had earlier built a classroom for one of the Madison Migrant Camp and clinic, and now contributed to the building of the Broderick Salud Clinic.  The Yolo County branch of the American Cancer Society provided a grant for training of  seven Community Health Workers, who both worked and learned there during their two year training. A Salud Community Health Worker Training Manual was published for that training.

I dedicate this history,  in general, to the Salud Clinc Board, to the community that gave support and life to the clinic,  and to UCD students who worked on the building; but in particular to the Salud Community Health Workers- CHWs.  I recently discovered a pile of old slides documenting some of the building and operation of Salud Clinic. It was a substantive and  substantial two year training program, devised to permit  local people without prior  medical training, to become the pimary link to immigrants and working poor  folk who are peers of the health workers. Most CHWs were middle aged women. One was an ex felon. There is somewhere in the US government  copyright archives a copy of the  Training Manual; I only have some  photocopy ready  master pages.  which appear below.

 

 

The building  at 530 C Street was one of those 1 3/4 story wooden structures but it was well located on a 1/2 acre lot and had a complete apartment on the second floor, suitable for meetings and training, or for a resident FNP or physician. The rat infested downstairs was completely gutted and replaced with a medical office including lab, Xray, waiting room, records and reception area, medical office and two examing rooms.

The clinic was immediately very busy.  Donations were requested but scant. I billed Medical when possible, though the paperwork would have made that a losing proposition except for the health workers.  The Board approved doing phase III investigational drug work, which  paid very well, and provided participants with complete physical exams and partial care.

 

Salud  Health Foundation had been formed to help develop the first Migrant Farm Worker Free Clinic in rural Yolo County.[2] Medical student Paul Hom, who would later become the Director of Public Health for Sacramento County, was also a lawyer. He suggested a non profit corporation  in order to help build and operate it and later also  did the legal work for the incorporation of The Salud Health Foundation in Broderick.

That name, salud,  was familiar to Spanish speakers because it means ‘health’ as well as   ‘Drink up!’  Many people in Broderick when we first spoke of Salud rhymed it  with ‘mud’  , which  ironically nicely described the drinking water in Broderick at that time! [3] The Salud Health Foundation had helped the ” U C Davis Amigos”, a group of students, to build  a  clinic  building for migrants at the Madison Migrant camp, near Esparto in West Yolo County. One may still pass it with the stampede of gamblers headed to Cache Creek Casino.

We proceeded at Broderick with the strong support of the Broderick Christian Center and the Broderick-Bryte Neighborhood Council. East Yolo lawyer William Dedman acted as consultant to the board.

October 6, 1970 Council Meeting:  The Salud East Yolo Board formed, and drew up bylaws and organizational papers. They continued to meet regularly at the Christian Center.  Emilio Lopez (Human Rights Commission) was elected president of the Board of Directors. Pete Villarreal took on the job of fund raising.   Carlos Salinas (Washington Unified School District) chaired the Building Committee, with John Pagett sub chair for Carpentry, French Francis (Bryte Council sub chair), Electrical, and Ray Gutierrez for grounds, [4] Lillian Newton PHN, was Publicity Chair, Janette Vaughn, East Yolo Youth Council representative, , and  Carlene Sharples, Welfare Worker, Legal Chair.

On November 22, 1970: Escrow was signed for the 530 C Street building, in Broderick, to be converted to the Salud Clinic. With the was an trash strewn  adjacent lot to the East, that we hoped to make into a community garden.   Though the lower ¾ of the building was rat infested,  neglected and run down, but  the structure was solid, and had the added virtue of a wedge of vacant land for parking  in front of the building on C Street and expected  to acquire in time from the State, as it had no other useful purpose. The old house was decorated with a sign:  Salud East Yolo Medical Facility, with plans to open in 1971.

Mike Kolar, UCD student who had been a driving force in the building of the Madison Migrant Camp Clinic had graduated and was hired part time to reconstruct the building as part of his conscientious objector deferral from the military draft. The Salud Health Foundation assisted in raising funds, with much community support.  There were pages of donors mainly in amounts less than $20.00.

November 28, 1970: Curiously, there was a  sudden flurry of interest from  Central Yolo County. Captaine Thompson [County Director of Mental Health Services] organized a meeting of dignitaries and the Salud Board of Directors.   His wife, Helene Thompson, became a  permanent  critic of the Salud effort, but never appeared there,  or spoke to the Board, to me, or to the Broderick community. The result of this flash flood meeting was that  people who had never darkend the door of Salud, or been to a board meeting descended on rather politically unsophisticated, powerless people, and  overwhelmed them.  It did not go well;   The Board felt abused, and  insulted.  I have noted some quotes in my record:

Dan Kelly, Administrator, Woodland Memorial Hospital (read Woodland Clinic).

“You are naïve.”

Glenn Snodgrass: UCD Medical School:

” UCD Med School is fully committed and (therefore) unable to help.”

Emilio Lopez: Board President Salud E Yolo Medical Clinic

“The trouble with outsiders is you go home to your cushy life and remain ignorant of our local reality.”

French Francis:  an elderly man, who is a fairly typical Salud Board Member: “We don’t need any help. Or want it.”

January 4, 1971: Every weekend volunteers worked at the building. We lunched at the Broderick Christian Center. Adolph (Tiny) DiGiulio was the 300 lb genius who organized the meals. He  reportedly solicited food like day old bread and slightly outdated vegetables and meat from known but safe sources. Whatever the truth, the three course meals with beverage were simple, tasty and ample, and usually cost Salud about $20 for 20 people, including but not limited to:

Alex Creighton,

Lloyd Newhall,

Emilio Lopez

Felix Mejia

Jessie and Alberto Rodriguez

John, Fred, and Robert Loofbourow

Carlos Salinas

French Francis

John Pina, and

Chuck OHara  and others from  Johnny’s Time Out Bar

The Jay Cees

It is awkward for me to list these names, because I’m certain there are many left out. For example, I recall Steve, a UCD student, but can’t remember his last name. I apologize to those many volunteers, with only the excuse that almost 50 years have passed by since I saw you last. Mike Kolar, worked with many local people during the week to meet the complicated code requirements of a commercial building that included lab and X-ray ( radiation health requirements),  as well as the usual medical office setup in a commercial grade building. The Second floor was rehabilitated for meetings and training of clinic staff.

We always were short of funds of course. We knew that the shortage is a cost of freedom or independence. So there were many dollar productive activities that we, and I, were involved in over the next few years; some were contracts for services that I took on, others that the board accomplished; anything that allowed us to complete the building, and later to support operations. These included Auctions conducted by the Board and work that I did like:

A contract with Yolo County Compensatory Education to do 200 child exams.

Consultation with EOC  and David Pollard ,to   train  and supervise staff for Senior Screening Clinics, in  Auburn,  Forest Hill, and environs. The community health workers assisted.

Contract with the Sacramento Concilio  New Careers Project providing Health Workers with the option to go  to Sacramento Community College half time. One immediately was accepted in  nursing school full time, but of course, had to resign.

Consultation and testimony regarding pesticide legislation (Petris SB432)

Family Planning clinics in Yolo county and at Salud.

On the recommendation of   Dr. Helen Kleviscus, a volunteer in the Yolo County Migrant Clinics, we applied for, and the Board of Directors of Salud agreed to participate in, a drug trial for Abbot Labs. This would now be called a phase III investigation, and while it was not so well compensated as similar trials today it was not only very helpful economically, but provided participants with a  complete physical and lab workup, as well as basic health care during the months of study.

 

May 21, 1971 Opening of Salud Clinc with participation in the ‘Rub out Rubella Campaign.

Herbert Sabin, volunteered as clinic nurse. He was a dedicated worker, although admittedly quite autocratic or aggressive in treatment of patients without consultation. Whatever his defects he made a valuable contribution to the early clinic operation, even though the board later had to negotiate about a child who had a temporary subcutaneous fat  loss after Herbert had given a steroid injection without consultation.

Sept 1971- UG 1973:  A Community Health Worker ( CHW) Training Program.

 

We felt that the soul, the ethic, and the driving force of a community clinic were to be found only aong the most genuine and typical people in the community itself. The physical manifestation, the body,  of that soul, must be in a Board of Directors, and in the people who work in the clinic. It is manifest by  deeds, language, culture, and shared experience. Broderick was a cradle for diabetogenic and atherogenic dietary diseases;  alcohol stricken families  and individuals; and tobacco toxic lung, kidney, and heart disease. Violence,  and interpersonal abuse must have been common but we didn’t see it often; perhaps, because most people have become hardened to it, or are fearful of discovery.  Perhaps because we, the clinic and board,  didn’t last long enough to see it or recognize it.

The environment was often dismal, or harmful; water, for example was rust and mineral laden, and so dirty that it was often opaque. Students brought tap water from Davis when they volunteered to work on the building, and began to bring it for others during especially bad water periods.

Since Salud was not able to easily alter heredity or economic circumstances  we proposed to try to affect the community behavior and understanding of health matters.  We would train local people to not only work in the clinic but to know  of  and speak to the main factors affecting health there.[5] Emilio Lopez and I presented a grant  proposal wrote to the American Cancer Society, where I had earlier served a board member, while in pracitce in Woodland.  The proposal was predicated on the idea that the development of cancer, social and behavioral diseases, and chronic medical illness, are  generally a many years long process, beginning with life style and environmental conditions as well as heredity. Health Workers became the dominant feature of the Clinic from that time forward.

The CHW  training lasted two years, based on a very comprehensive manual. I don’t have one now, though a copwright copy exists somewhere in the some fedreal ardchive somewhere.  Illustrations and diagrams were beautifully and professionally done by Sandra Tiller.  The  admittedly polemical philosophy came from me. The cover featured an upraised arm  and fist holding a snake, a sort of cadeucus.  To give the reader a feel for the extent of  training, amateur but readable shots  of the print ready  table of contents are pasted below:

September 1971: Interview and selection of CHW trainees.

Victoria Odem

Ray Rubio

Carmen Shelley

Geraldine Hernandez

Raquel Carmona

Mary Romo

Joan Schauberger

One additional student violated parole and left the program, and Raquel Brown was accepted for training as a Registered Nurse, so that Joan Schaubarger took her place, and became biller/ bookeeper.

March 1, 1972 Dick Noble was hired as part time physician, but left abruptly without a word in September without offering reason. Ouch. He may  have been offended because our clinic was not altogether free. Though we never billed patients without insurance, accepting only donations from others, we billed Medicare and Medical. On the other hand that would seem a curious objection, because Dr. Noble was paid a very  significant retainer. But he left without a word except ‘ Pig’ written on his desk… So much idealism.

July 1972 Data on 600 Senior Citizen Screenings[6]: approximately 50 % have abnormalities of vision, Blood pressure*, hearing. Most of the assesment was done by CHWs.

10% fasting blood sugar diagnostic of Diabetes*

5% anemia

3% abnormal intraocular pressure.

* These abnormalities are based on old criteria. Today the % would be much higher because criteria have been tightened considerably.

September 25 1972 A proposal to the California  Community College system to develop a career ladder for CHW training and progression, beginning with a program to train and certify CHWs was rejected

January 6, 1973 . The Salud CHW Training Manual,was adapted for use by George Kent in the  Chico State Satellite Closed TV training projects. [7]

February, 1973 The clinic continues to be  busy, seeing nearly 50 patients daily. Yet Salud has not yet become self sustaining.  I realize, and our Board does too,  that the ambitious and probably arrogant — os a critic said, naive–attempt to provide medical services without accepting government funds will not succeed unless I continue to subsidize the operation at about $2000 monthly.  My physical and personal, or animic,  resources had been drained. ‘Revenue Sharing’ had been started by the Regan  federal government, and we reluctantly appled for Revenue sharing funds.

May 21,1973:  It is  two years after the opening of Salud. Our Federal Revenue Sharing Grant receives preliminary approval. But it must have the assent and consent of the Yolo County Board of Supervisors.  The Supervisors approve only on the condition that the operation be turned over to the Yolo General Hospital or to the Yolo County Public Health Department.[8] Our choice: ( Ouch!! Thanks so much.) The County agrees to continue to give the Board of Directors an advisory role, and to purchase the building at ‘cost’ but without consideration for all the volunteer efforts,  contributions from the community or others, including myself. They reason that it is counterproductive to have competition in caring for the need; foolish to add a third entity in the county to provide care for indigent people.  After discussion by the Salud Board we elect to go with the Health Department, under the direction of Otis Cobb. Our quixotic quest is over.

The meaning of ‘advisory’ becomes clear to the Board. After a brief time the original Salud clinic at 530 C Street is abandoned by the Health Department and moved to the Public Health facility nearby. Our cherished little medical office with lab and X-ray was put to some worthy non medical use. The county apparently altered or  improved the clinic building, and acquired the parking area in front, something we were not able to do. In the next few years I occasionally visited the Public Health building in Broderick. Salud was housed in an old school near the I Street Bridge.  I felt it operated reasonably well, but I sensed the spirit was losdead despite great commitment from the staff.. Despite the sincere and tireless efforts of many devoted nurses and physicians, despite the agreed retention of all our health workers, medical services are so foreign to the public health industry that  it appears they were unable to adapt.

To quote John Siden:

” Although Salud was subsumed under the health dept in the early 1970’s, soon thereafter all the county’s health functions were administratively reorganized and the clinic became a branch of Yolo General Hospital’s outpatient clinic…  It acquired a little more of a look of a traditional clinic, but in fact it was always the ugly step sister as far as the hospital was concerned.  But it had a dedicated and devoted staff, from the health workers through the MDs.

The (original) organizing effort was so powerful that to this day the… Salud Advisory Board that lives on in county ordinance is listened to by local politicians far in excess of its present strength. …The forces (of) … the early 70s were still at work when the county set out to replace its facilities in WS in the early 90s… (including) a new Salud … (W)hen the hospital was closed in 1991 the clinic operations were taken over by Davis Community Clinic (now Communicare).”

Salud had come full circle, arriving to it’s beginning as a community clinic

Toward the end of the CHW training, we all realized the board could not pay for the original purchase of the building,which I had bought at the outset;  nor could they reimburse me for remodeling costs or meet ongoing clinic operation costs.  So, reluctantly, because it was a pact with Satan,  I   applied for a Revenue Sharing Grant from the Federal Government. Salud was approved for the funding;  but there was a caveat– of course!  The Yolo County Board of Supervisors woule be required  to approve also.  I had foolishly or perhaps  arrogantly  never courted the Supervisors; they approved only on the condition that the clinic be sold to the county,  at the original cost, to me,  and turned over to either the County Dept of Public Health, or the County Hospital.

By that time my wife had sued for divorce; I knew what my contribution to our problem was:  I had essentially abandoned my family to care for migrant workers and Broderick citizens, while working several jobs to support the whole lot.  I had failed in all respects, as husband, father, and physician, and  organizer. I was exhausted, irratable, and completey burned out. Had I been in better shape, I might have  refused the demands placed by the Supervisors, and even, perhaps, my wife. But I completely caved on both counts,  abandoning  my share of our  family assets, and the clinic s well, and moved into a Residence Club at 22nd and V St in Sacramento. I suppose i was as depressed as the rest of my elderly, lonely, or cast off neighbors, who became a sort of second dysfunctional family.

And time sometimes heals. Ultimately, I left what I liked to call the  private practice of community medicine, and worked the last 25 years of my active medical life as in Emergency Medicine, the last 20 at Kaiser PMG in Sacramento until retirement in 2000. That was the second most fortunate and significant event of those years. The first was that I remarried; I still marvel at that after some 41 years, growing up through a midlife adolescence into the second childhood orf old age.    But Salud Clinic still survives,  being  resuscitated and kept alive lives,  thanks to the Community Health Workers, FNPs. and and the clinic physician,  David Katz.   

The county, like me,  abandoned Salud and turned it over to  Communicare, a Yolo County association of Free Clinics based in Davis that devolved  from the Davis Free Clinic movement. Of their several  clinic operations, Salud is the most active, profitable, visible,  and viable.  It has retained Community Health Workers, who remain the key element in communicating with that polyglot clutch of diverse people.  Salud doesn’t pay much attention to the Board, though it exists, and retains the idealism,  innovative spirit,  and dedication characteristic of the Salud model.

The political and social growth and demise of the original clinic was the subject of an extensive and perceptive report by Donna Fazackerly of the UC Davis dept of Sociology.  I think often of Salud, and  try to stay aware of the changes over the years. I have lunch occasionally  with Salud Medical Director, David Katz, and try to keep track of John Siden. We speak about  the same people we did in the ’70s. Among all the changes, there is one that is, most happily,  unchanged, one thing that pleases me more than any other. The CHWs,  soul of this community clinic endure. CHWs still provide interpretation not only of language but of spirit, and community,  through a vital connection with patients that could never otherwise take place. The heart of Salud beats faintly  in the breast of the Board of Directors; but it lives on.

All have my sincere admiration and gratitude for resuscitating, preserving, and further developing  that which the people of Broderick, Bryte, and West Sacramento  gave birth to so long ago. Because of you May 21, 2017  began the  the 46th  year for Salud.

Thank you. And:  Bravo!!!

John Loofbourow


[1] One generations is often very different from the next, each unaware of the values and physical reality of the other. These buildings were structurally and hygienically marginal, and rents were $75, the equivalent of $200  now.  Yet I believe  they compare very favorably to neglected motels, public housing, and rest homes. They offered a certain freedom, an independence, even a dignity, that was reflected in the way the residents interacted with one another and the surrounding community. The residents were from an age past, with their own set of truths and values, quite foreign to us, their hypercritical descendants.

[2] I have a long 1966 list of  migrant camps in Yolo County alone. Some 10,000 workers were required yearly from March to September. With the help of the Yolo County Health Dept, County Hospital, and Medical Society, we established four night clinics with follow-up at the Yolo General Hospital.  the most busy  and admirable were Madison camp,   and the Mace Ranch to the South of El Macero,  which housed several hundred men in a big bunk house,  and 6 or 10  families in small homes, and provided meals and a full time cook and meals. I always ate there after clinic.

[3] For a perceptive study on the East Yolo and the development of Salud, including the water problems,  see Donna Fazackerley’s ‘The Politics of Health Care in East Yolo‘, which she submitted as a Senior Project for the UCDavis Department of Applied Behavioral Sciences in June 1973. Donna moved to Broderick and lived there for three months in preparing for her report.  I also still  have a 4 page history of Salud.  It relates the development of the facility and includes a nine point exposition of the Salud concept for Community Clinics.  It ends with the notation “Salud- Power to the People, 1972.”

[4] There were many more. Among them Alfred Biles, Chuck Snodgrass, Ray Pines, Paul Gutierrez, David Ingberg, Alex Creighton, Gary Oschner, Tiny Di Julio, and Fran Molina were sub committee members, some on more than one committee. Fred Adams, Harold Hocker, Lloyd Newhall and  Len Ortiz( plumbing),   These were the people who  would sustain   Salud in the difficult times ahead.

[5] The training course  was held  five afternoons weekly for 6 months, and was relatively intensive, contionuing thereafter once weekly.  Though the Salud CHW Training Manual  was adapted by other programs,  and went trough several revisions, I now have only the templates for the first two sections and the Table of contents, for the original version. See appendix. ( I am missing section 3.)  Although local community colleges declined to offer a course or a career ladder for CHWs, it was offered later elsewhere.

[6] An El Dorado OEO project for Senior Citizens where CHWs performed most of the screening, and abnormalities were referred to local physicians.

[7] I later was hired to develop a CHW training project for a federally funded HMO project in Sacramento. However it lacked community support and control, relying solely on millions of federal dollars,  stillborn from the cold  federal womb, but  provided a great living for a few handmaidens.

[8] Ibid: The Politics of Health Care in East Yolo. The problems and deliberations of the Board are presented with sympathy and accuracy by the author.

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