Community Health Workers
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.