“Every undisclosed payment, free sample or all-expenses-paid trip is an attempt to manipulate. And whenever clinicians or researchers take the bait, it’s patients who are put at risk”. R Pearl Forbes Dec 10 2018
There is ample and well documented evidence of the way drug and medical equipment manufacturers co-opt and groom both physicians and the public. (1) For physicians the evidence is all around us. Physicians accept:
Gifts that influence medical decisions or practice.: :
Meals, and samples from attentive, attractive drug ‘reps’.
Subsidized Continuing Medical ‘ Education’ ( read grooming!)
Subsidized or free medical meetings
Free samples of costly drugs to promote later sales.
Physicians are not quite innocent in accepting such freebies; we know there is a payment due, but fail to make the obvious conclusion: Don’t accept the bribe!
ProPublica Dr B gave overly favorable reviews for Swiss drug company Roche but failed to disclose $3 million in direct payments from the company since 2014, claiming the lapses were “Unintentional”!
Brigham and Women’s Hospital in Boston revealed that Piero Anversa, a high-profile physician and cardiac stem-cell researcher, had falsified and/or fabricated data in at least 31 medical journal publications.
Tito Fojo, MD, PhD in The John Conley Lecture found that “the last 71 chemotherapy agents receiving FDA approval extend life by an average of only months—time often spent in pain, isolated from friends and family.” (2)
Misleading Direct To Consumer TV ads largely pay for ‘free’ TV. They are often so misleading as to be absurd; but they work! When an ad claims that a drug, “significantly increases the chance of living longer” What does that mean? Nothing! Another ad can state that a medication ‘can improve (symptoms) ‘ up to 75 %’ That must mean-75%-100 % may see no improvment! ( Step right up Ladies and Gentlemen! See the two headed woman grow another body!)
Medical trials funded by drug companies are 30% more likely to show their drugs are safe and effective compared to independently funded studies, according toa consortium of medical and statistical experts (the Cochrane Coalition.)
Is there something physicians could do? Various new Oaths have been written:
I swear to fulfill, to the best of my ability and judgment, this covenant:
“Hippocratic Oath: Modern Version
Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University (Good, but anachronistic in 2019)
I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.
I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of over treatment and therapeutic nihilism.
I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.
I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.
I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.
I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.
I will prevent disease whenever I can, for prevention is preferable to cure.
I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.
If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.
“The original oath is redolent of a covenant, a solemn and binding treaty,” writes Dr. David Graham in JAMA, the Journal of the American Medical Association (12/13/00). “By contrast, many modern oaths have a bland, generalized air of ‘best wishes’ about them, being near-meaningless formalities devoid of any influence on how medicine is truly practiced” Probably modern oaths are written by a committee or by congress! (Sorry.My rant…Ed)
I agree the modern oaths are not much improvement in the 21st Century. We live in a new era, the equivalent of the time when the printing press and cheap paper appeared; what followed then was constructive chaos because information, and commuication only available to the few, became available to the many. Isn’t that what is happening today on a much wider scale? A world wide scale? It is as true of medical information as everything else. Therefore even if we physicians may refute or ignore the assertion that we are complicit in the prohibitive cost of US Health Care, we should realize that is irrelevant; we are no longer in charge. Who is? Our world with almost unlimited access to information formerly confined to the elite of medicine: to us. If we think we are in charge we could read Marcia Angel’s book; and if we still want to be the alpha wolf of medical care, simply going on line and looking up any disease, condition, medication or treatment option should abuse us of that illusion. Is there reason to reconsider the ethical practice of medicine? Even by drug companies? Yes!
If so, physicians should do that both individually, and collectively through professional organizations. We cannot absolve ourselves from being complicit by saying “ I myself wasn’t paid millions.” Rather, we could consider this: “I sold myself far more reasonably, like most of my colleagues! Still, I am not altogether innocent; I realized there would be some kind of payment due, but failed to make the obvious conclusion: Don’t!:”
I graduated under the old oath, from the University of Minnesota School of Medicine in 1954 and have been grateful every day of my life. There is no more privileged, challenging, joyous, or fulfilling work. Some things do not change! Not yet at least…
We should consider an Oath something like this which:Recognizes that patients have more access to information and therefore are more able to participate in medical decisions about their health and health care, and reads as follows:
Conduct myself in the most rational and far sighted way I can, avoiding careless, thoughtless, or self serving prescription of medications or procedures that may harm the biosphere, or the health of my
patient or the bioshphere, or the wider community.
Honor traditional, rational and moral standards of medical ethics but willingly discuss and render my opinion about those I feel are unwise or harmful.
Refuse nominally free continuing medical education (grooming) through enticements.
Honor my patient as I do myself, being always willing to take time to explain the reasons for my opinions and always ready to listen and consider respectfully my patient’s ideas, concerns, objections and wishes.
Honor my patient’s right to choose among the various options for treatment or nontreatment.
Condemn and Reject Direct to Consumer Advertising by drug companies, manufacturers of medical hardware or devices; and by physicians or other healers.
Refuse payment for unmerited ‘research’ and speaker fees; where these may be justifiable, I may accept only after independent peer review and a commitment to total transparency.
Always take into consideration whatever effect my practice may have on the environmental, medical, biological, and economic aspects of medical care.
Alwaysbe ready discuss and to adjust my fees according to my patient’s request, regardless of any presumed ability to pay.
Respect the ethical guideline of medical care, Primum non nocere, First Do No Harm, while carefully taking into consideration my patient’s personal needs choices, and wishes.
Hold my patient’s medical history, diagnoses, and treatment to be privileged communications between us only, unless my patient directs me to act otherwise, or when consulting with a medical colleague about a difficult case, where the consultation is also a priveleged communicaion.
(1) Among the best reading on the subject are:
The Truth About Drug Companies by Marcia Angel, MD. For many years she was editor of the New England Journal Of Medicine. (ISBN 9780375760945)
Overtreated by Shannon Brownlee (ISBN: 9781596917293)
Mistreated: Why We Think We’re Getting Good Healthcare—And Why We’re Usually Wrong,”by Robert Pearl MD (ISBN-13: 9781610397650)
(2) JAMA Otolaryngol Head Neck Surg. 2014;140(12):1225-1236.
(3) No doubt freedom of speech could be claimed in defense, and yet Direct to Consumer Advertising is like shooting an automatic weapon into a crowd. Freedom to kill with an automatic weapon is the same sort of crime as killing through dishonest and deceptive advertising. One is killing for its own sake, the other is killing for profit. Neither is protected free speech!)
This is to suggest that when there is a “Take Care Of Your Diabetes” conference nearby it is worthwhile for those with, or at risk of, diabetes; likewise for medical professionals. I attended the TCOYD conference here in March 2018, though I had never done so before; it was offered for about the 6th time in Sacramento, and many hundreds of times in the nation. For professionals at this session the conference cost was $30, and less for others. It was held at the Convention Center, attended by at least a thousand people. There were no openings for walk- inns. The general idea is this: People with an inherited predisposition, or diabetes, or abnormal diabetes screening tests of any sort, are encouraged to do simple things themselves to prevent later problems. Moreover medical providers may discover more about ways technology promotes patient personal involvement in the care of chronic disease; and, I believe, about the direction and future of medicine. Joan Borbon clued me in to TCOYD. We volunteer at a local Student Free Clinic. So I signed up. For me, personally, the whole day was a triple delight.
First, because the general thrust concurs with one I have long practiced: That in chronic disease treatment and prevention, people must be their own principle care-givers and managers. Diabetes is the perfect example. Why? No one can manage the illness without the direct personal understanding and involvement of the diabetic or pre diabetic; no Doctor, Legislator or friend or family member. But technology places the means to do so in the hands of the individual. For example, in diabetes, the personal Blood Glucose Monitor allows people, 24/7, to measure and control their own disease. No more time consuming lab or office visits, days long waits for test results. Moreover, in the forseeable future, access to reasonable, personal technology and information will make self care ever more practical and efficient. In my own little lifetime, it seems to me the most significant development in diabetes care has been the personal BG monitor, which has become acessable, reasonable, and simple to use.
Second, because I, a stubborn, arrogant macho man, ignored my own clear symptoms and family history for at least 15 years before discovering my own diabetes…never listening to my life, never thinking about it.* Maybe signs of diabetes were so easily overlooked because my routine screening tests were always normal; my doctors and I relied on them without another thought. But if we had considered my family history, or even listened to the voice of my body, we could have discovered my type 2 DM much earlier.
Many people with an interest in diabetes attend the conferences over and again, gradually learning more and more about the disease. And yet, while the conferences are very informative, perhaps it's wise to keep some things in mind:
- Even if addressed mainly to the general public, these are medical conferences; they are funded completely by people who want to sell stuff–caveat Emptor — Buyer Beware.
- The eloquent and impactful speakers, aided by great media, are partially bought and paid for.
- The literature is as skillfully crafted to subtly mislead as are magazine or TV ads.
- The booths are staffed with highly trained professional salespeople. Beautiful, engaging people.
Third, The program is varied and relaxed enough to allow for casual unhurried conversation. A personal note: I like to run and sniff the world like an escaped hound dog. But always, even in childhood, Northern California has been the home where I return ever, where my family history and heart and dearest memories also live; as a physician, it’s been my medical home since 1959. Therefore in this broad focused meeting I often met up with old colleagues or friends who share an interest in diabetes. Steve Edelman, who many years ago concieved and organized TCYOD, was a Med student at UCD when it was still on the Davis Campus where I occasionally lectured; Demo Pappagiannis who coached and wrote several papers with me on coccidioidomycosis, was there. There were many other friends, colleagues, and physicians from Kaiser, UCD, Woodland, Davis, and Sacramento. And nurses; perhaps most of all. .
Nurses and P As are the Hands and Heart of medical care. Brooks Smith and I were the first lecturers for the UC Davis Rural Family Nurse Practitioner training program. It was in the Dept of Family Pracitce headed by Hughes Andrews, and managed by Mary Fenley and Leona Judson. Since then,– 45 years ago– it has evolved fast, grown, changed names, and fled the skirts of the Med School into the arms of Nursing. At the conference every local Nurse Practioner and PA I spoke with was a graduate of that particular program.
TCYOD is based in San Diego) at the center of a world of Spanish speaking folk with diabetes and prediabetes. Therefore A Cuidese Su Propio Diabetes– CSPD– is needed. If I were still crazy I would volunteer; but I am less insane now. Maybe someone can use material in Spanish I wrote for diabetics in Colonet, Baja CA. ¡Quizas!
* But during the first years of symptoms I was working day and night 7 days a week, rather doggedly doing My Thing with migrant worker night clinics, and Regional Rural Health which they grew to be, and Salud, an inner city clinic in Broderick, CA. At the same time I worked at UCD to establish an Occupational Medicine Program, and took on many consultant jobs in order to provide for my family, 6 people whom I supported but otherwise mostly left on their own. I was Sick, Out of My Mind. Over time I gradually developed severe bilateral lower extremity neuropathy. As my usual diabetes tests were normal, neither I nor my doctors explored diabetes further. A neurologist confirmed the neuropathy, but asked: Do you drink? Yes occasionally. Well! He said, Don’t. A podiatrist ordered some $400 shoes. I had had a laminectomy in 1975 for and acute disc with foot drop, with lipiodol studies, so a CT was done. Nada. I ignored some other things: that my neuropathy was better when backpacking – and burning a lot of glucose. That the cold bothered others it didn’t trouble me. That my balance was slaightly off. Only after several years of worsening neuropathy did I order an old fashioned four hour Glucose Tolerance test. Bingo! Ironically, today anyone with a personal blood glucose test kit can do that home alone. I”m happy to say that the neuropathy has receded with control of my disease.. like many people, I detest initialisms and acronyms but they are epidemic;; as they say, It is what it Is. IIWII. So, TVOYD; Listen To Your Body. LTYB; Listen To Yor Family, their words acts, troubles, and History. LTYF; Hear, Think, And Do. HTAD.
I recently took a friend to the hosipital with severe septic shock from acute influenza. After one day of typical acute flu– sore throat, fever, headache, tight cough and prostration– she developed most of the characteristic signs of sepsis. On registering at the emergency department, the symptoms of sepsis were recognized, and she was admitted immediately. Within minutes after appearing at the registration window, more than two liters of saline were pumped into her through to IV lines; more would follow. After about 10 hours all her vital signs, pulse, temperature, and respiration, gradually returned to normal, and she was released. The diagnosis and treatment were immediate and effective.
Septic shock can be the result of any overwhelming infection that causes the body blood circulation– and therefore multiple organs– to fail. It is seen most often with a bacterial infection, but in this case was caused by a virus: type A influenza. When someone comes to the ED with fever over 100, heart rate over 100, and respiratory rate over 20, (an important but often overlookied vital sign!); and in the worst cases, mental confusion and low blood pressure– it is Sepsis, septic shock requiring immediate treatment, just as with heart attack or stroke or poisoning or respiratory failure; it’s that urgent. Accurate diagnosis and multiple lab tests are far less urgent than immediate treatment, based on symptoms and findings. Over the next few hours her lab tests did come back, consistent with influenza, including a nasal rapid test for type A influenza.
Sepsis sometimes kills people during the current flu epidemic, or pandemic… It can also kill from influenza pneumonia, or complications of preexisting heart or respiratory problems, especially in the aged, and paradoxically, the very young. Type A flu constantly mutates, changing so much that the old flu vaccine is little help, precisely because it’s derived from the last few epidemics, while influenza has moved on, evolving and changing ever since. So in this and most epidemics, people are almost all on their own, even after a flu shot, although arguably that immunization does no harm.
With symptoms of influenza, one should go to bed and stay there, drinking at least a liter of liquids three times a day, until you are without fever and well hydrated. If the symptoms of sepsis are suspected, go to the nearest hospital. Tylenol/ acetaminophen/ ibuprofen/Motrin, may relieve symptoms some, but aspirin is not advisable. If one get by for 4-5 days, expect gradual recovery over a few weeks, with productive wet cough. Tamiflu (oseltamivir) helps at the very first. It’s expensive, and requires a prescription, unfortunately. Of course the manufacturer suggests it be taken for much longer; in my opinion, that is profitable, but isn’t as effective as taking it on the very first day. ( I confess. My bias is: ‘follow the money’. )
It is curious that the last great worldwide lethal influenza epidemic took place almost exactly 100 years ago: The pandemic of 1918 killed many tens of millions, then a great part of the world population; deaths were comon among people with ongoing serious chronic health problems, or malnutrition, when treatment was less effective than it is now, especially treatment of secondary bacterial infections.
Well, that’s my take on the 2018 flu. But then, thankfully, I am only an old ex-doctor, ( I love that!) So you,the reader, must realize this is just gossip, worth less than what you pay for it!
We’ve been probed, CT’d and MRI’d,
Have suprapubic midline tatoos,
And golden marker seeds inside
To show gamma ray binocular eyes
Where to send high energy rays
to the place where cancer lies
awaiting a deadly dose of Grays.
We arrive, our bladders full,
With a Fleet’s clean sigmoid;
Identified, pastic bracleted, we pull
Off our clothes and try to avoid
More exposure of bare buttox
To watchful target cathodes
waiting in cold whiteness.
We are cheered by nurse and technician
Who treat us like aged newborn babes
And carefully swaddle us in position.
They leave. The machine wakes, and stirs,
To mufflled beats of rap that plays;
It rotates, stops, starts, and whirs
To shoot off focused gamma rays,
Until the prescribed dose is spent;
Then deflates the swaddling wrap,
sighs, and stops, as if content,
and settles down to take a nap.
Our nurse helps us to our feet,
pulls off our wadded sheets,
Then sets it all in order again
For friends of Grays and Fleet’s
I don’t know why I was admitted to the U Minnesota Medical School one month after turning 19, without a particularly impressive undergraduate record. In large part I attribute it to my friend who mentored me in High School and Pre Med. He is the friend I have known and loved longest; all my prior friendships had been fleeting; that is a downside of being raised in mining towns all over the world, which has distinct and unique advantages, but long-lasting childhood friendships don’t happen. We met in High School when we both were moved to Minneapolis in a Minnesota cold mid sophomore January 1946; despite time distance, and different roads travelled, we have been close friends ever since.
During pre med years it was his suggestion to take engineering physics and chemistry rather than pre med classes, because Med School acceptance was unlikely; there were many highly qualified applicants, among them those with real life experience, like marriage, work, or serving in WWII; they were far more mature by any measure, than we. Yet we both were accepted in the Fall of 1951. The U of M Medical School apparently saw something in us. He was a better scholar than I, but they also saw something in me that I did not. From my point of view it was a great leap of faith on their part.
However, I was only a child who didn’t know who or what and where he was. My needs, as I saw them, were social, and economic rather than intellectual. I had to pay my own way, by working part-time, and migrating to California in Summers to do farm work. I was able to work for room and board at a Fraternity; in those days that was possible. My brothers often carried me. I was welcomed, and participated socially, fully enjoying those relationships while trying to appear grownup; but all that was at the cost of academic excellence. I graduated near the bottom of my class while my friend and mentor was near the top. Looking back, I regret not being a devoted and excellent student, but did what was most urgent for me to do.
While my mentor is well-known in Minnesota medical politics and in business circles, a permanent and significant part of the community, I am a generalist and soloist in every sense of the words.That is as true in medicine as in my life itself. My MD degree has been a passport to places, people, languages, and human experience what is sometimes called the private practice of public health. My CV seems more remarkable for its breadth, rather than its depth. After 60 years of medical practice we both, my friend and I, remain active in retirement; he in business and medical politics, while I consult, mentor, volunteer, read, write, and blog. In mid 9th decade we are in fairly good health, and may need to continue for a few years more.
I have few regrets. I doubt my mentor does either. And yet I would have liked to also have had an adult physician mentor during med school. I had no ongoing personal interchange with any particular faculty; academic medicine is a demanding master– or mistress, to be more politically proper. I believe it would be ideal if all med students had a physician mentor, someone they talk or meet with regularly to discuss the life of physicians and students; perhaps a mentor who is a blood and guts doc in private practice, whether group or solo, with a volunteer clinical appointment under the aegis of a Medical School. 1 I my case, however, my mentor is still with me. Our lives as physicians have been quite different, reflecting our natures; and yet we have traveled separate roads, and the same road, together. In the words of Robert Frost, ‘that has made all the difference.’
1 As an aside, physicians are not the only people in medicine; medical people are increasingly interdependent. I find that undergrad students who are interested some aspect of medicine benefit greatly from an association with the School of Medicine in general, and with physicians in particular. As a preceptor for student free Saturday morning clinics, I find pre med and other medical undergrad students are the muscle, heart, soul, and guts of the clinics, which are not easy to fund, organize, and operate; such clinics simply would not happen without enthusiastic active undergrad students. No one else has the time, motivation, and enough fire in the belly.
This is a history and memoir about the Salud Concept of communty medical clinics, and its impact on the the Salud Clinic in Broderick California, which opened on May 21, 1971, and still operates on its 46th anniversary in May 2017. Details and time line are taken from public documents, board minutes, and personal records. I dedicate this history to the Board of Directors; to the community that gave rise to the clinic; to the Broderick Christian Center which encouraged and nourished the seminal ideas of the Salud Model, and the building of the of the clinic itself; to the entire staff, but in particular to Salud Community Health Workers and Family Nurse Practioners.
In October 1968 Central Broderick was an older unincorporated town like West Sacramento, the adjacent relatively prosperous port and residential community of West Sacramento, and Bryte, the smallest town, home to many East European immigrants, notably those from Russia and the Ukraine. Collectively the towns were known as West Sacramento or East Yolo. Older streets are still lined with one and three quarter story buildings, like those seen in central Sacramento; the lower level rises only seven feet above ground. They had been built that way in expectation of frequent flooding common many years before. As flood control became more effective these low-ceiling spaces began to be used for living or storage.1
With the completion of the cross country Lincoln Highway in 1916, travel boomed. The auto court was the way people settled for the night. Many large tree shaded lots were later converted into trailer parks, and in Broderick, some were filled with clusters of ten by ten wooden shanties, without indoor plumbing, rented to single men. Despite attempts to condemn them, these shanties, sometimes owned by politically powerful people, survived until incorporation of the city in 1988 2.
East Yolo was a short distance in miles, but over 50 years distant in time, from Yolo County administrative centers in Woodland, where county services and low cost medical care were available at the Yolo General Hospital. Across the Sacramento River were the State Capitol, and the the Sacramento County Hospital, but medical care was not readily available there to uninsured Yolo county residents. There were two West Sacramento pysicians in private practice. Many people survived in an economic and political backwater even though Yolo County maintained a Dept of Public Health office and a sheriff’s substation in Broderick. There seems to have been a self effacing humility; the I Street Bridge is still named for a Sacramento alphabet street, and the area of West Sacramento, sounds like an appendige to a cross river county.
I arrived in 1959, and was the only Spanish speaking physician in the county until eight years later our office took on a bright new partner, Brooks Smith. We become the first physicians for the Family Nurse Practitioner ( FNP) program at U C Davis; we hope that FNPs will work in small clinics and towns under the supervision of a licensed physician who need not be physically always on site. The Salud Model concept develops after Herbert Bauer, former Yolo County Director of Public Health gives me a long list of places where migrant workers live seasonally.3 That leads to a series of small free night clinics for migrant workers in rural Yolo County. The first is at Madison; it’s still there on highway 16 just before getting to Esparto, hardly noticeable to people en route to Casche Creek Casino.
A pre-medical student Paul Hom, will would later become the Director of Public Health for Sacramento County, is also a lawyer. He creates a non profit corporation, The Salud Health Foundation, in order to help build and operate the several migrant farm worker clinics. These have the support of many local volunteer physicians. That name, Salud, is familiar to Spanish speakers because it means ‘health’ as well as ‘Drink up!” Some non Spanish speakers in Broderick, later rhyme it with ‘mud’, which rather nicely describes the drinking water in Broderick at that time… so bracksh that some people bring their own when working to build the clinic there. 4
The Foundation first helps the ” U C Davis Amigos”, a group of students, to build a clinic building at the Madison camp. Later, people from Chico, Woodland, and small rural Yolo County towns, like Yolo and Esparto, request assistance to develop clinics. I am able to explain the Salud Concept of community clinics, and the process; but projects require more than ideas. or words. They require commitment, and action; I can advise, but not commit or act on them all.
In a short time there are two more bare bulb Migrant Health Worker weekly evening clinics; my favorite is at a large operation on the El Macero Ranch, south of El Macero. A two story building holds a large bunk house for up to 100 men upstairs; below is a big dining room and kitchen. There are family units adjacent. Meals are delicious, ample, and authentic. After clinics I always chow down and schmooze with the cook.
Men who immigrate for farm work one way or another, are gererally economic pioneers, admirable adventurers, like those of the Gold Rush… at least as I see them. They are generally healthy enough to invade illegally, work, live on very little, and send money home. When I was young I interpreted for them during the WWII Bracero program; much later, often live with them during my own summertime migration from Minnesota to work in the N Calif almond industry. In time that pays for my college. We are thereore generically, and animically, brothers, even though I work for myself, while they do mostly for relatives. Many stay on indefintely, some spending a lifetime alone and estranged from the family they support.
A friend in Woodland was an elderly peg legged cook at a small restaurant where I often ate lunch. He had lost a leg in a Texas farm accident at age 18. One day he told me his daughter, a judge in Leon, Mexico, was flying in to the local airport; could I take him to meet her? Of course; we picked her up from her private plane and went to lunch. But the enconter was quite ugly, confronttional and difficult. She made clear he was an uneducated old man; and worse, a victim of the abusive capitalist Yanquis who stole half of Mexico, and abused and oppressed Mexicans. He made clear that whatever she had achieved resulted from his work here, which he was grateful, for and proud of. He loved the this ncountry and the people. End of visit. I took her back to her plane, and him to his work. Such personal stories are not rare.
Of course there were also women and children in migrant worker camps, in families who move with the crops, mainly people who live in other parts of the US. The children in particular often had health problems: anemia; parasitosis; malnutrition related to diet where the hallmark is a mouthful of stubby decayed yellow teeth; silent tuberculosis; inadequate immunization for childhood diseases; chronic otitis. The beauty of those conditions is that all are easily diagnosed and treated. The Yolo County Health Department and the County Hospital were very helpful. 5
In a few years the UC Davis School of Medicine appears on the Davis campus. The migrant clinics are interesting and appealing, with superb medical and community support; they address the needs of farm workers, an important ethnic community. Very alertly, the school of medicine asks for help to submit a several million dollar Federal Grant application and it is approved, with UCD administrative responsibility for the project. Unfortunately two complications quickly impact the project:
First, by the time the University obtains control, technology has already changed Yolo County agriculture amazingly rapidly and radically. Seasonal migrant workers have been replaced by chemicals and machines; they are no longer needed, at least not here. Second, the medical school mismanages the program, perhaps because their main challenge, and burden, is to build a new school from scratch, rather than provide migrant care. They lose the grant.
However the project is large, and significant from a human and political standpoint. There is a need for basic rural health care in small towns, the same situation that Salud conceptt addresses; and there is a desire to support Spanish speakers in education and in health. So the migrant project is salvaged, becoming Regional Rural Health, RRH, generally along the lines of the Salud Model with the addition of bilingual education, a popular idea of the time. RRH, managed by a Spanish speaking Board of Directors, would establish bilingual rural primary schools and offer health care to local people of all sorts. Salud Clinic, meanwhile, proceeded at Broderick with the strong support of the Christian Center and the Broderick-Bryte Neighborhood Council.
Paul Gutierrez and John Siden introduce me to Broderick. Paul was disillusioned with the politics of the Economic Opportunity Council; although he told me nothing of the details, apparently the feeling was mutual. He wanted to open a food service for the poorer residents in the area and call it Paul’s Kitchen, and to organize the community to develop a health care facility. He and Jess Perez had gathered some 4000 signatures in support of a clinic. John was director of the Broderick Christian Center, and expressed similar hopes regarding health care. The Center hosted a series of meetings where the focus was a health facility. It remained the planning, meeting, and eating place while the clinic was built. Without that support the clinic would not have been built. I was invited to discuss the Salud concept with emphasis on local control, and ownership, by a Board of Directors. The council decided to adopt a comprehensive plan for the Salud East Yolo Medical Facility.
October 6, 1970 Council Meeting: The Salud East Yolo Board forms, and draws up organizational papers. East Yolo lawyer William Dedman acts as consultant to the board. They continue to meet regularly at the Christian Center. Emilio Lopez, (Human Rights Commission) is elected president of the Board of Directors. Pete Villarreal takes the job of fund raising. Carlos Salinas ( Washington Unified School District) chairs the Building Committee; John Pagett is sub chair for Carpentry, with French Francis. Ray Gutierrez, (Bryte Council) electrical, and grounds. 6 Lillian Newton PHN, Publicity Chair; Janette Vaughn, East Yolo Youth Council; and Carlene Sharples, Welfare Worker, Legal Chair. For many years Lillian has been tireless in promoting dental health for E Yolo children.
November 22, 1970 Escrow closes on the building in Broderick. It is condemned and the lower floor reeks of rat offal, but it has some unique assets besides rats: 1) it comes with a second lot to the East that could be a community garden. 2) the main structure is solid; 3) there is a wedge of vacant land in front of the building that could be used for off street parking, and might be acquired from the State, as it has no other useful purpose. 3) a complete second floor apartment is in good condition.
The condemned house is brazenly named the 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 addtion, had graduated and is hired part time as part of his conscientious objector deferral from the military draft. The Salud Health Foundation assists in raising funds, with much community support. They have many pages of donors mainly in amounts less than $20.00.
November 28, 1970 There is a sudden flurry of interest from Yolo County. Captaine Thompson [County Director of Mental Health Services, organizes a meeting with Yolo County dignitaries. It does not go well; Thompson’s wife becomes a supervisor, and remains always a staunch critic of Salud, as frankly, are most of the visiting noaries.
Some quotes from my personal 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 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: Salud Board Member and favorite professional curmudgeon:
“We don’t need any help. Or want it.”
January 4, 1971 Every weekend volunteers work at the building. We have lunch at the Broderick Christian Center. Adolph (Tiny) DiGiulio is a 300 lb genius who organizes the meals. Rumor has it that he solicits 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 are simple, tasty and ample; they usually cost Salud about $20 for 20 people, including but not limited to:
Jessie and Alberto Rodriguez
Fred, and Robert Loofbourow
John Pina, and
Chuck OHara and others from Johnny’s Time Out Bar
Members of the Jay Cees
It is awkward for me to list these names, because I’m certain there are many missing. For example, I recall Steve, a UCD student, but can’t remember his last name. I apologize to those volunteers, with only the excuse it’s more than 45 years 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 including lab, and lead shielded X-ray. The Second floor is used for meetings and training of clinic staff.
We always are short of funds of course. Arguably, that shortage is a cost of freedom or independence. There are many inventive activities that we, and I, are involved in over the next two years; some are contracts for services, others things that the board accomplishes; anything that allows us to complete the building, and later will support operations. These include:
A contract with Yolo County Compensatory Education to do 200 child exams.
Auctions conducted by the Board
Consultation with EOC to organize, train and supervise staff for Senior Citizen Screening Clinics, coordinated by EOC director David Pollard in Auburn, Forest Hill, and environs.
Contract with the Sacramento Concilio New Careers Project providing Health Workers with the option to go to Sacramento Community College with half time support.
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 apply for, and the Board of Directors agrees to participate in, a drug trial for Abbot Labs. This would now be called a phase III investigation, and while it is not so well compensated as similar trials today it is very helpful, providing volunteer subjects with a physical and lab workup. Many have never had that experience before.
Broderick was ground zero for the diabetogenic and atherogenic diet, the alcohol stricken family and individual, the tobacco toxic lung, kidney, and heart. The environment was often dismal, or harmful; like the water previously noted; I felt that the soul, the ethic, and the driving force of a community clinic lives only within the community itself. The physical manifestation of that soul can be reflected in a Board of Directors, and by their operation of the clinic, involving people in the community.
Therefore I write a grant proposal for A Community Health Worker ( CHW) Training Program for submission to the Yolo County American Cancer Society, where I had previously served on the board. The grant application is predicated on the idea that the development of cancer is generally a many year process– like many other chronic health problems– greatly affected by life style and environmental conditions. As in many such efforts, students from U C Davis contribute greatly. I wrote a Training Manual and the art work for the cover reflects not my orientation but that of the student artist. It consists of a raised fist, which grips a snake like caduceus! It was copyrighted, and used by various training programs elsewhere, and yet, i don’t have a copy, much to my disappointment.
There is a time-honored principle of Public health: No law, or fine, or regulation is very effective in changing harmful personal behavior; what is effective is when people conclude themselves that a beneficial behavior is in their interest. The corollary is that nothing can be so effective to improve health as involving people who are a part of the community itself. Emilio Lopez and I present the proposal to train CHWs, and it is approved. We are forever admiring and thankful for the Cancer Society sprit, and intelligent foresight; oterwise I don’t think the CHW project would ever have been completed.
We would train local people to both work in the clinic and learn about the main factors affecting health in the community.7 Community Health Workers, and later, FNPs become the most effective and unique feature of the Clinic.
May 21, 1971 Opening of Salud Clinc with participation in the ‘Rub out Rubella Campaign.
Herbert Sabin, volunteers as clinic nurse. He is a dedicated worker, always There, decisive, authoritative, dressed in his white uniform. He is capable and experienced in Xrays. On the other hand he is a take charge guy, often dramatic, who likes to Intervene in a way that makes me uncomfortable. I am a more conservative minimalist who likes to keep in mind how our citizens suck up pills as if there were never any side effects; and feels that Beg Pharma and Big Tech seed TV and the ‘news’ with misleading true lies. Observe that today’s medical consensus is all to often tormorrow’s medical sin. As it turns out the board later has to negotiate about a child with a temporary patch of subcutaneous fat loss after Herbert gives a steroid injection without consultation. It was a minor self limiting complication, but at the time, looked ugly.
September 1971: Interview and selection of CHW trainees.
Raquel Carmona left for nursing school was replaced by Anna Sankey
A felon, who violated parole was replaced by Joan Schauberger
March 1, 1972 Dick Noble, MD, is hired as part time physician, but leaves abruptly in September without giving notice other than writing ‘Pig’ on his desk. He had never objected and never said why he was so intemperate or outraged. Maybe we couldn’t pay him enough; or What? It was not as if he worked for free! So much for radical idealism, if that is what was in play… Ouch.
July 1972 Data on 600 Senior Citizen Screenings8: ( % approximate)
50% abnormalities of vision, Blood pressure*, hearing.
10% fasting blood sugar diagnostic of Diabetes*
3% abnormal intraocular pressure.
* These abnormalities are based on old criteria. Today some % would be much higher because criteria have tightened.
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 is rejected
January 6, 1973 . The Salud CHW Training Manual, in which the beautiful artwork is done by Sandra Tiller, is adapted for use by George Kent for the Chico State Satellite Closed TV training projects. 9 Now CHW Training projects are everywhere, base on the very same concepts we developed at Salud.
February, 1973 The clinic continues to be busy, seeing nearly 50 patients daily. Yet Salud has not become self sustaining. We all realize that the ambitious and arguably arrogant attempt to provide medical services without accepting government funds will not succeed unless I continue to subsidize the operation at about $2000 monthly or become the government myself. That makes me slightly sympathize with Congress; but only for an instant can I sympathize with people who live high, and exempt themselves from laws and regs they lay on the rest of us. But my physical, emotional, and personal resources are drained. I am divorced, and my contribution to that personl loss is having pretty much abandonded my wife and children in favor of Farm Workers, Broderick and even, I suppose, to my own fading idealism, which might be viewed as ambition.
‘Revenue Sharing’ has been started by the Regan government, and I reluctantly apply for funds. I know, as does the board, it is a pact with the devil. But.. Who Else?
May 1973 Two years after the opening of Salud our Federal Revenue Sharing Grant receives preliminary approval. Yet the devil is here: the Yolo County Board of Supervisors must agree. They reason that it is wrong to add a third ( and relatively independent) entity in the county to provide care for indigent East Yolo people. Their approval requires that 1) the entire operation be turned over to the Yolo General Hospital or to the Yolo County Public Health Department; our choice! 10 2) that the Board remain only as an advisory body. 3) that the County acquire the clinic for what I originally paid for the building, without consideration for what the community or anyone else invested. We smell brimstone and sulfur, but agree, providing:
1) We are assured the CHWs individually and as a role model be kept as employees with full benefits. 2) The advisory status of the board be documented. After discussion the Salud Board elects to go with the Health Department, under the direction of Otis Cobb. If I or the Board had more determined, if we knew our true strength, one of us might have refused; in view of the nature of politics, the County very likely would have back tracked. But I ,for one, was whipped, not sure whether I was Faust or Don Quijote.
After a brief time the original Salud clinic Street is abandoned by the Health Department and moved to a building nearby. Our cherished little medical office with lab and X-ray will be put to other uses; maybe. The littered lot remains as it was, though perhaps the county improved the clinic building; they acquire the parking area in front, something we were not able to do. In the next few years I occasionally visit when Salud is in an old school near the I Street Bridge. It operates reasonably well, and health workers are included. Yet there is a sense the sprit is dead despite devoted and inspired efforts of the physicians, nurses, FNPs, and CHWs who seem unable to move the Public Health behemoth into the arena of Primary care. Maybe that is inevitable, because it that kind of service never has been the Health Department’s primary job.
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 rather meek and mild 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 ( and far more luxurious ) Salud … (W)hen the hospital was closed in 1991 the clinic operations were taken over by Davis Community Clinic (now Communicare).”
Salud has come full circle, arriving at its beginning as a community clinic. Nonetheless, the new owners are absentees, and distant; they are not familiar with the local reality; they have far larger and more significant concerns, even though Salud remains the most active, profitable, and productive of their several clinics, like an ugly stepsister who is otherwise admired by the polyglot and multicultural community for her CHWs and FNPs, and the constant, consistent, and persistent devotion of David Katz, the chief Salud physician, who has a long history and awareness of the Salud Model and concept.
After Salud is suibsumed into the county government, the RRH, stepchild of the Migrant Health project survives, but barely. I still have a soft spot in the brain for them, and agree to become medical director. They build a Dixon clinic and rent space in Esparto, and Courtland. For a couple of years I try to breathe life into those operations, but fail miserably. The millions of Federal dollars fade away. I leave but am still unwilling to let go of my own illusions, and then agree to become medical director for a Federal project attempting to create an HMO for Sacramento, where CHWs and FNPs are key providers. But again, the Federal DNA is fatal, and after a number of million dollars, the patient dies. Yet, I am cured, at least superficially, give up the private practice of Community Health. I devote my next 25 years to Emergency Medicine, to my family, and to traditional medicine
The most significant personal events of these past nearly fifty years have been: First, 41 years with my fierce and stubborn but tolerant wife and children; Second, 25 years in Emergency Medicine, the last 20 at Kaiser PMG. I think often of Salud, vaguely aware of the changes over the years.
For a while after retirement I volunteered at Salud; it was rewarding to care fpr the same patients we saw early on. Salud, nominally, has come full circle, arriving at its beginning as a community clinic. Nonetheless, the new owners are absentees; they are not familiar with the local reality, the people, the history of Salud, or the concept. It seems they have far larger and more significant concerns to attend to, though Salud remains the most active, profitable, and productive of their several clinics– a weird stepsister who survives and is adored by locals for polyglot and multicultural CHWs, for FNPs, and for the persistent effort of David Katz, who has a long history, devotion, and awareness of the Salud Model and concept.
Recently I spoke with Katz, and found the clinic name on line is name is now Communicare Health Center. Yet there is much unchanged–The CHWs and FNPs remain the body and soul of the operation, providing interpretation not only of language and culture, but of spirit, and community, through vital connections that would never otherwise exist. The heart of Salud remains the Board of Directors; it beats only quietly in the background, but it is alive.
To my family, my love, sincere admiration and gratitude for patiently or at least kindly tolerating my excesses; and to you all at Salud , for preserving, and further developing that which we began to create so long ago. Because of you May 21, 2017 was the 46th anniversary of the opening of the Salud Clinic.
1 See three articles in the March 2004 History issue of Sierra Sacramento Valley Medicine pp 5-20. Trappers came down from Oregon finding only the Sutter Buttes sticking up out of an inland fresh water sea; they brought malaria with them which decimated the native population. Cholera came up the river and decimated Sacramentans. In the 1850 flood of Sacramento, Dr Morse, whose office was on the second floor, floated dead bodies in the water below, until they could be moved. That was a very bad year!
2 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, but rents were $75, the equivalent of about $200 now. Yet they compared favorably to neglected motels, public housing, and rest homes, precisely because they offered a certain freedom, an independence, a dignity, in the way the people interacted with one another and the surrounding community. The renters were from an age past, with their own set of truths and values. Single, usually older men, could be called bums. But they were a driving force in building Salud, and active on the Board.
3 I have a 1966 list of 117 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. Later the UC Davis School of Medicine opened and became involved. However within a very few years agricultural practices changed so radically that the camps are nearly all gone, and migrants generally seek work elsewhere. The migrant clinics became obsolete.
4 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 have somewhere a 4 page history of Salud, author unknown. 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.”
5 We had to send stool samples to be examied for parasites, and of course the parents collected the samples, and took them to the hospital lab. I had once a wonderful letter from a lab technician where he colorfully described how he would arrive at work to face a clutter of bottles and cans, filled to the brim with stools. He hoped we would teach migrants how better to collect save the specimens.
6 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 sustained Salud in the difficult times ahead.
7 The training course held five afternoons weekly for 6 months, and was relatively intensive. Though the Salud CHW Training Manual was adapted by other programs, and went trough several revisions, I have only the templates for the first two sections and the Table of contents, for the original version. ( I am missing section 3.) Although local community colleges declined to offer a course or a career ladder for CHWs, it has been done elsewhere.
8 An El Dorado OEO project for Senior Citizens where CHWs performed most of the screening, and abnormalities were referred to local physicians.
9 I later was hired as physician and developer of a CHW training project for a federally funded HMO project in Sacramento. However it lacked community support and control, relying solely on very generous ( millionary) federal funding requiring a huge federal burden of oversight. It died almost as quickly as the money disappeared.
10 See: The Politics of Health Care in East Yolo. The problems and deliberations of the Board are presented with sympathy and accuracy by the author.
Democracy destroys itself because it abuses its right to freedom and equality. Because it teaches its citizens to consider audacity as a right, lawlessness as a freedom, abrasive speech as equality, and anarchy as progress. Isocrates, 436-338 BCE
Some 2360 years ago, Chios, Cos, Rhodes, and Byzantium bolted from the Athenian Confederacy over abuses of central power by Athens. Isocrates wrote a long essay urging peaceful resolution of the conflict. It was surely not delivered orally for the reasons he mentions in the opening paragraphs:
“…you do not hear with equal favour the speakers who address you… while you give your attention to some, in the case of others you do not even suffer their voice to be heard. And it is not surprising that you do this ; for in the past you have formed the habit of driving all the orators from the platform except those who support your desire …you ( cause them to say) not what will be advantageous to the state, but what (pleases) you. …how can (we) wisely pass judgement on the past or take counsel for the future unless (we) examine and compare ( opposing ) arguments? …although this is a free government, there exists no ‘ freedom of speech ‘ except that which is enjoyed…by the most reckless… .
It sounds very 21st century USA, doesn’t it?
In the mid 15th century, thanks to the printing press, common people began to acquire printed material containing ideas or knowledge formerly limited to wealth, state and church’ which were joined at the hip. Later, In 1522, Luther published the bible in vulgar German, instead of Latin, making it widely accessible for the first time. Over the next hundred years wildcat or unschooled publishing exploded, causing rulers to fear a access to information- arguably knowledge- putting power in the hands of a gullible and ignorant public. In 1641 Britain–to protect the public (of course) !– made all printing illegal without prior official approval. Two years later a defiant John Milton published Aeropagitica, a title he adapted from Aeropagitcus, where Isocrates urged the revival of the Aereopagus, a court to control education of the young and public immorality.
Since the1990’s the internet has become exponentially available to an entire world. Authority is challenged or attacked by unschooled, unapproved wildcat non line e.publishing that is consumed by an awakened, restive national and transnational public. Free Speech is again so intolerable that Isocrates’ stale words echo down the hallways of time, and it seems clear that –again– civil dialogue and speech are true lies that recur throughout what we call history. While in the past, technology driven change required centuries to come to a boil, this pot took only a few decades to boil over.
I try to believe our little e.fire will cool down, that we will control the pot of the e.verse. Yet it seems even more techno-crises are almost upon us: artificial intelligence; bioengineering; bioprinting; robotic automation and their spawn; Mars; and driverless cars (though two story high trucks of open pit copper mines in Chile have not had drivers for many years.) I was once an arrogant little pilot, like so many physicians who fly and sometimes die. But long ago on a several week trip to Punta Arenas, on the straits of Magellan, I found that even a simple array of instruments was a better pilot than I. Therefore, thinking of the unknowable, which is now seems almost everything ahead, I know that–looking back– my greatest good fortune was to become a physician, not so much through merit as luck, and the influence of a friend. To study my physician predecessors and colleagues is to move outside my own limits. It reminds me of this from Empedocles:
The nature of god is a circle of which the center is everywhete and the circumferance is nowhere—!
and this from Mathew Arnold’s Dover Beach:
I say: Fear not! Life still
Leaves human effort scope.
But, since life teems with ill,
Nurse no extravagant hope:
Because thou must not dream, thou need’st not then despair
So today, wanting a dose of something other than alcohol, I pulled down Osler, but quickly put him back, in favor of pulling him up : such is the joy of a browser! Aequinimitas was his valedictory address, University of Pennsylvania, May 1889. He spoke of the physician’s need for equanimity:
“ clearness of judgment in moments of grave peril, immobility, impassiveness, or, to use an old and expressive word, phlegm.”
Phlegm! How choice a word for equanimity that is! He continues in that grandiloquent elite euro-greco-roman slang :
“in the Egyptian story…Typhon with his conspirators dealt with good Osiris; …they took the virgin Truth, hewed her lovely form into a thousand pieces, and scattered them to the four winds; and, as Milton says, “from that time ever since, the sad friends of truth, such as durst appear, imitating the careful search that Isis made for the mangled body of Osiris, went up and down gathering up limb by limb still as they could find them; We have not yet found them all,”
And there it is again! The quote is from Milton’s ...Areopagitica!
The Areopagus as viewed from the Acropolis.