Global health care needs in rural areas: An essay

By Lilia G. Hernandez, MD

There is a town in south central Washington, between the more progressive cities of Yakima and the Tri Cities (comprised of Pasco, Richland and Kennewick). Speed limit is at 35mph, 25 at most streets, 20 when children are present. And there are many of them, giving me a first impression this must be a town of young families. (Pop: 38.1% <18 yrs.)

I first arrived here March 15th 2010, when the temperatures were 30s Fahrenheit at night, 50s during the day. My first impression was of a flat land, most are planted, miles of vineyards and hops along the highway. There are small rolling hills into which the vineyards are inching up. In the early morning, the cool air smells of cow dung, which the locals call the smell of money, the sure reminder you are at Sunnyside, WA. This was desert land until damming of Columbia River provided irrigation that transformed the land and wealth of the area.

I came to work at a Pediatric Clinic to help a doctor who has been the only Pediatrician in this town for over 20 years. When the local hospital wanted to expand services, it opened clinics around the hospital and in neighboring towns. Dr. Anne Nealen used to be a missionary in Africa, working there for over 2 years, before getting married and settling in this town. Her pediatrics practice was absorbed into the Sunnyside Community Clinics and after over 2 years of recruiting, the hospital hired a 2nd pediatrician who stayed for 2 ½ years. Dr. Mario Tobia was of Filipino heritage, married to a Caucasian Canadian lady. When he left, I came as a locum tenens to fill in until a new doctor could be hired.

I soon learned the obvious, that this is a farming community. The population are >85% Hispanic who work the fields and farms. The Clinic population reflected this. Darigold and other dairy farms are located here, so are acres and acres of farmland for apples, grapes, hops. Many of the mothers I see are seasonal workers, many of the fathers work “en el campo” or with cows. One of the large clinic systems here is the Yakima Valley Farm Workers Clinics (YVFC). The Yakima TV station (KIMA) estimated the undocumented aliens here are as much as 40% of the Hispanic population.

As I go through my day at the Clinic, I quickly note that most of my patients do not speak English. The office workers are very ready to assist me in translating if the case is more complicated (ADHD, congenital defect, etc) but I am so glad for the Spanish we had to take in college and the vocabulary I had picked up practicing in California, before “retiring” and doing locum tenens.

On my first week, I was struck by the number of congenital anomalies I was seeing: 2 girls of about the same age with only 1 normal external ear, the other side had no ear canal, and only a small stub for pinna (microtia). Children born here (documented citizens) with various congenital defects and developmental delay. Seattle’s Children’s Hospital have specialists see many of them at the Children’s Village at Yakima, a site created so parents and children can see multiple specialists at the same site in one day. After a couple of weeks, I started asking if there were data showing the percentage of the population with congenital anomalies, ADHD, depression and various mental illness. It just seemed inordinately higher to me compared with populations of other towns I had been to before. I was wondering if this was simply an impression on me. After all, the waiting period to get into the Children’s Village for neurodevelopmental or other specialists’ evaluation was over 7-9 months. No one seems to be aware of any data. No one thought the presence of the Columbia River, once polluted by the Hanford nuclear facilities in WWII would be a cause or a factor. Much of the economy of the TriCities was fueled by the nuclear clean-up (Google Hanford).

As I see these children in the streets, and their parents, the immigration debate came to my mind. Here is another dimension that is not talked about. Clearly, these men and women work the fields to get America fed at the price we pay in the groceries. The American Academy of Pediatrics has noted in one email that fertilizers may be responsible for learning and developmental defects. Are many of these men and women, in their effort to earn for their families, who risk their lives crossing the river, irrigation canal, or the desert at the border, also inadvertently risk the future of their children? If these are not “undocumented” “illegal immigrants”, would there be a study made, a louder outcry? Or is this just an impression, not based on statistical analyses, on a pediatrician who has dedicated over 25 years of her adult life to the care of children in the United States?

I have a Hispanic last name but of Asian descent. I am a citizen of the world, an immigrant before becoming a citizen of this country, and my travels have helped me look at the human race as inherently one.