GUEST VIEW: Partnership in health care along the Rio Grande/Bravo

The fourth year of medical school is supposed to be the last hoorah before dedicating the next 3-7 years doing a deep-dive of your chosen specialty, and so when I was invited to take a spontaneous road trip to the US-Mexico border to participate in rural community engagement, I had to say “Yes”. The plan was to travel to Candelaria, TX, a predominantly Spanish-speaking community of about 75 inhabitants, to participate in a health forum providing preventative health screenings and patient education. Driving alongside the Rio Grande with breath-taking views of the Chinati Mountains to the east and the northernmost stretch of the Sierra Madre Oriental to the west, it was sobering to think about the barriers to care these rural populations must overcome to access medical attention.

When we arrived at the re-purposed “former” schoolhouse where the health forum was being held in Candelaria, we were warmly received by Texas Department of Health and Human Services (TDSHS) workers (from El Paso, Presidio, and Austin) adorning Santa hats and reindeer antlers. Soon thereafter, the schoolhouse was buzzing with children ready to learn about preventative oral hygiene and adults interested in measuring their blood pressures and glucose levels. This relatively small event required collaboration between multiple levels of government organizations as well as the support of health professionals (a dentist, a dental hygienist, a medical assistant, a medical student, two resident physicians and a faculty physician) from various fields. To see community health at work and experience first-hand how physically isolated this tiny pueblo was from any major hospital was an invaluable lesson in the necessity of rural health engagement. It doesn’t require a stretch of the imagination to consider the complications a resident of Candelaria would face if they needed emergent workup for possible stroke or intubation after a traumatic accident.

As a medical student, we are preoccupied with processing the mountain of foundational clinical knowledge necessary to build our skills upon in residency, and so it can be easy to forget that healthcare and the medical profession encompasses so much more than the exam room or the surgical suite. Sometimes, medicine takes you a few hundred miles downstream of the Rio Grande to a quiet community nestled in the foothills of the Sierra Madre.

— Dalynn “Andy” Kim, MS-IV

TTUHSC Permian Basin

As a new full time academic physician within the Rural and Community Engagement Division at the TTUHSC Permian Basin campus, I was delighted to take Andy and our two Alpine based rural Family Medicine resident physicians, Cristina Rivera MD and Alex Bustamante MD, to the health fair in Candelaria, TX. Prior to August, I practiced full time in the Big Bend area living in Alpine but traveling to outlying federally qualified health clinics in Marfa and Presidio twice weekly. For most of my 16+ years of practice in the Big Bend, I have hosted both medical students and resident physicians in our clinics and critical access hospital in Alpine because I enjoy exposing trainees to both the joys and challenges of practicing full spectrum family medicine in an under-resourced rural environment. I feel that these rural experiences are necessary for future physicians to understand the challenges that rural patients have in accessing care locally as well as the challenges that rural physicians have in providing care in these environments. In fact, the literature shows that any rural exposure in training for a resident physician is strongly correlated with future rural practice.

My wife and 2 youngest sons were delighted to meet Andy and her husband for dinner at a local Thai restaurant in Alpine the evening before we left for Candelaria. I wanted to use the meal to meet her and her husband for the first time, I wanted my family to meet them and I wanted to debrief about the 300-mile trip from Alpine to Marfa to Shafter to Presidio to Ruidosa to Candelaria and back that we would make the following day. We had a delicious meal and fellowship together. We learned that neither Andy nor her husband had ever been to the Big Bend. Andy, as a fourth-year medical student, had never done a rural rotation although she had volunteered for a similar health fair in Ft. Stockton recently. She was excited to have the opportunity to drive to one of the most isolated frontier communities in Texas, Candelaria (population about 75 inhabitants). Candelaria sits on the banks of the Rio Grande (Rio Bravo as it is known in Mexico) river. Candelaria has no access to local health care or any commerce in Candelaria. Residents of Candelaria can cross the river over a wire bridge to access a physician in Mexico in the neighboring Mexican village of San Antonio Del Bravo. The nearest US health care is a 120-mile round trip away at the FQHC clinic in Presidio from 8 AM to 5 PM Monday through Friday only. The nearest emergency room and labor and delivery unit is that same 300-mile round trip to the area’s only critical access hospital in Alpine.

Several times in the past decade, the FQHC has partnered with the TDSHS Office of Border Public Health to put on a health fair in Candelaria. One of the Associate Commissioners of Health from the TDSHS joined us and we were able to learn of the state’s public health efforts in far to reach places like Candelaria as well as to plan how the FQHC and TTUHSC could work with the state to serve populations such as Candelaria. We were able to offer blood pressure and glucose screenings and health education primarily in Spanish to the roughly 50 community participants. A TDSHS dentist and his team did cursory pediatric dental exams and applied fluoride on their teeth. We helped hand out Christmas gifts to the children of Candelaria. And, we took pictures with Santa “Poncho” Claus and the Grinch. We ended the day by walking to the wire bridge on the river.

On our return trip to Alpine, we stopped at the Presidio FQHC to drop off a medical assistant from the clinic who had accompanied us. We had a visit with a TTUHSC El Paso neurologist and ophthalmologist and their team who were working to set up telehealth equipment at the clinic as part of a US Department of Agriculture grant.

It was rewarding to me to have representation by two TTUHSC campuses in the Big Bend that day attempting to improve health disparities and access to care issues in a rural medically underserved area of Texas. I also remembered a quote from Dr. Paul Farmer, “Our most significant professional accomplishments in life will be done in partnership, as a team.” My hope for Andy and all other health care professionals in training is that they have an opportunity to experience rural health care as part of their training. I hope that Andy and other students will choose rural health care as their future careers. I am proud that TTUHSC prioritizes rural health care and makes opportunities such as a trip to Candelaria or Presidio available to students.

— Adrian Billings MD, PhD, FAAFP

Associate Academic Dean of Rural and Community Engagement, TTUHSC PB