Dateline

In Presidio County, you’re a long way from anywhere.

The vistas are grand; the frontier is staggering in its raw, volcanic beauty. What does that mean, though, when your child has an asthma attack, or your husband suffers chest pains? How far is too far when it comes to medical care?

The border town of Presidio is an hour and a half drive, 90 miles, to the nearest U.S. hospital, the Big Bend Regional Medical Center in Alpine. Presidio has one ambulance, and it’s just about kaput. Sometimes the ambulance crew calls ahead to Marfa, some 60 miles north, to arrange a midroute transfer. On the roadside, the patient is shifted to Marfa’s EMS ambulance for the rest of the trip. Woe to you if you’re Presidio’s second emergency of the day and the ambulance is already out on a call.

With about 5,000 people, Presidio has one full-time physician and another who’s there once a week. Up the road on Highway 67, Marfa has 2,400 people, two art foundations, a half-dozen art galleries and two bookstores, yet no physician or pharmacy. People with serious medical issues must travel to Alpine, 26 miles east into Brewster County, to see a doctor or fill a prescription.

Presidio County is 3,856 square miles of creosote, grassland, rocks, and sky. The northern Chihuahuan Desert is unforgiving country. The county is among the most unpopulated and underemployed in the nation. Most wages here are well below what they are in the big city, the teenage pregnancy rate is twice the national average, and 36 percent of the county’s residents live at or below the federal poverty line. The drought that has nearly crippled the local ranching industry is slouching into its second decade.

Amid the challenges of isolation and poverty, a movement has taken shape to improve local access to medical care. In November 2003, two groups—one in Marfa and one in Presidio—began working to establish new clinics. Almost a year ago, the two merged to become Presidio County Health Services. A community-supported clinic in Marfa will celebrate its first anniversary in November; a new clinic is in the works for Presidio.

At the center of these efforts are two very different women: Kate Wanstrom, a nurse practitioner, and Marilyn Sanders-McCrory, a retired pharmacology professor. The hurdles these women have faced and the approaches they’ve taken say a lot about the state of rural health care in Texas—and even more about grit and dedication.

Wanstrom moved to Marfa several years ago to become director of the Rural Health Clinic, a facility operated by the hospital in Alpine, which is, in turn, owned by Community Health Systems Inc. (CHS), based in Brentwood, Tennessee. CHS has a small niche in the health-care industry—operating small, rural hospitals. The corporation owns more than 80 across the country.

By the fall of 2003, Wanstrom was chafing under the corporate management of the clinic.

“I wasn’t willing to do more and more on less and less,” she recalls.

Hospital executives insisted that the clinic—which wasn’t breaking even—produce more revenue. Wanstrom complained that the facility was chronically and seriously understaffed. She believed that lackluster financial support had compromised patient care.

One busy Monday morning, the executives made an unannounced inspection. A couple of days later, they invited Wanstrom to lunch, where she expected a discussion about how to upgrade the place. Instead, the administrators gave her a list of 29 issues they wanted addressed immediately. Some action items were easy—throwing away the outdated bandages, for instance—but others, like the mandate to have a physician approve all sterile procedures, were harder. Over the next few days she began working on the list. Then she stopped, took a breath, and quit. “I could no longer reconcile working with such a corporate approach to medicine,” Wanstrom said. The receptionist—the only other full-time staff member—quit, too, in sympathy.

When word spread that Wanstrom had resigned, her supporters organized a town meeting to talk about creating a community-owned health-care facility. The existing clinic offered no sliding-scale payment plan. Nor did it offer mental health care, alternative health care, or dental services. The building itself needed significant repair. If locals were in charge of their own clinic, the organizers thought, then locals could make choices that were best for the community.

The meeting was held in Marfa’s AmVets Hall, a comfy old building with a stage at one end, a mural of the raising of the flag at Iwo Jima at the other, and a cockeyed chandelier in the middle. It was packed. More than 200 people showed up, about a tenth of the town’s total population. Hispanics, Anglos, old folks, new residents, and long-established families sat for two hours in polite, pin-drop silence as Wanstrom explained the idea of establishing a clinic. It was going to be hard, she said. A lot of work. And it’ll take time. Who wants to volunteer?

More than 60 signed the volunteer sheets that night, including Allison Scott, the counselor at the local high school. She’s credited with coining the catchphrase, “Better than nothing is not good enough,” which became the volunteers’ mantra. “All these people wanted to keep Kate here and provide better health care,” Scott said. “Why should we settle? Why can’t we ask for more? Why can’t we build more? If we can have two coffee shops in town, surely we can have two clinics.”

Wanstrom was overwhelmed. “My husband and I decided that if we had a meeting to gauge interest and 50 people came, we’d commit ourselves to trying to get a community clinic started,” she said. “More than 200 came. I think a lot of people were fed up with their clinic being such a low priority.”

During the same week as the AmVets meeting, a group of state and county officials was nearby talking Marilyn Sanders-McCrory, a retired professor, into a volunteer job that would eventually take over much of her life. The local officials and representatives of several state agencies were meeting at the courthouse in Marfa to focus on getting health services into Presidio.

Presidio sits across the Rio Grande from Ojinaga, Chihuahua, where the ocotillos come into their fiery, Dr. Seussian bloom in the springtime and the mountains loom blue all around. Poorer than Marfa, the community had long been on the radar of the state’s health agencies. State and federal money was available and waiting, the officials told Sanders-McCrory. They saw the chance to set up a Federally Qualified Health Center (or a similar kind of clinic called an “FQHC-Lookalike”) in Presidio. These clinics must offer comprehensive medical, dental, and mental health services, plus maintain a small, on-site pharmacy. Unlike a physician’s office or a run-of-the-mill clinic, an FQHC is eligible for 100 percent reimbursement for Medicare and Medicaid services, which greatly increases its chances of staying solvent.

“Presidio had always stuck out in their statistics as a place where this should be, but they didn’t know anybody [who could] launch it,” Sanders-McCrory said. Her flat Midwestern accent stands out in Presidio County, as does her scientific background, which includes academic grant-writing. Asked if she’d write a series of grant proposals to create a federal clinic in Presidio, Sanders-McCrory said she didn’t know much about health-care delivery. “I’m not a provider. I’m a basic scientist,” she recalls telling the officials. “I can research questions, I can write. They said, ‘Terrific.’ And I said, ‘Gosh, what did I get into?'”

Wanstrom and Sanders-McCrory had met, and had talked casually about health-care issues. What followed for each of them was two years of grant writing, fundraising, research, anxiety, workshops, board meetings, paperwork hustling, and exhilarating moments of optimism. They checked in with each other frequently, puzzling their way through health-care regulations and complexities. Wanstrom is effusive, has a great cackling laugh, and tends to blast her conversations with exclamation points, as in, “Hey! Look! You’ve got a fever!” Sanders-McCrory is more tortoise than hare, methodically moving from goal to goal, meticulous in her attention to detail, from the aviatrix scarf at her neck to the statistical charts necessary for a grant application.

Eventually a small salary was secured for Sanders-McCrory, though she has yet to cash a paycheck. “The organization needed the money,” she said.

Sanders-McCrory racked up enough state and federal grants to get the Presidio clinic open for a month last fall, but it closed for lack of a permanent, full-time physician or nurse practitioner. Though Presidio is undergoing a small economic and population boom, doctors and other health-care providers are not always attracted to a place so far from a hospital or urban amenities.

This fall, negotiations are in progress with Dr. Leo Altenberg, Presidio’s solo practitioner. A physician’s assistant who worked in the area a few years ago has moved back and is working at the Marfa clinic. When the Presidio clinic opens, he’ll go there once or twice a week to help. The application for FQHC-Lookalike status is in process. So is an application for federal Department of Agriculture grant and loan money to build a large clinic facility in Presidio. And the city of Presidio has obtained a grant that will pay for a new ambulance, which should roll into town soon.

Fundraising for the community clinic in Marfa has been distinctly more down-home. Supporters of the Marfa clinic held a barn dance, bake sales, and monthly rock concerts, all conceived, organized, and attended by Marfa’s young people. Five local families co-signed a $145,000 note on a former Baptist church that would become the clinic’s home. Hordes of volunteers showed up to renovate the building, donating free demolition, and then wiring, plumbing, and painting. The white-and-blue, homemade lighthouse on the roof—a holdover from Calvary Baptist days—remains. A religious organization in town called the Faith Alive Cowboy Church donated enough used dental equipment to fill two exam rooms. A mental health counselor appeared on the scene. A dentist moved onto a place near Valentine and was interested in part-time work. The Houston-based Brown Foundation came through with grants totaling $75,000. And clinic organizers struck a deal with county commissioners to provide health-care visits to the county jail, which brought in enough money to pay the mortgage and give Wanstrom a small salary. (In lean months, said volunteer Scott, Wanstrom won’t take any money.)

The Marfa Community Health Clinic opened last November. It offers clients sliding-scale fees for services as varied as treating the sniffles, doing “well-woman exams,” and dealing with the afflictions that beset a population in which diabetes and lupus are common. A dentist and a dental hygienist are in the clinic eight days a month, and a mental health counselor comes regularly. The place is booked solid and has been since it opened.

As opening day at the Marfa clinic approached, state health officials suggested that the Presidio and Marfa organizers consider a partnership. A single, countywide organization with clinics in the north (Marfa) and the south (Presidio) would stand a better chance of getting federal funding, the officials said. The two groups became Presidio County Health Services, and a new board was created. “I think this is an extremely important economic and social benefit to Presidio County,” said Sanders-McCrory. “There are a number of instances where businesses have wanted to come into Marfa or Presidio, and they haven’t because of the lack of health care here. We can’t afford to do that.”

Meanwhile, in May the Alpine hospital closed Marfa’s old Rural Health Clinic, where Wanstrom had resisted the “corporate approach.” The hospital’s new administrator is working with local officials on a deal that would pay Presidio County Health Services $4,000 a month to underwrite the Marfa clinic and other operations. (By law, the local hospital district has to maintain a clinic in Presidio County, an obligation that for years had been fulfilled by the now-defunct Rural Health Clinic.) Administrator Richard Grogan told the regional hospital district in July that there had been alternatives for the new contract in Marfa. “But we went with them because they do cover the entire county,” he said. “They represent planned clinics in Presidio as well as Marfa.” The monthly stipend, he said, “will speed up the process of getting a clinic in both communities.”

One night last July, Wanstrom was among the crowd at a joint called Ray’s Bar, Joe’s Place, or Lucy’s, depending on whom you talk to. Marfa had been temporarily taken over by an oddball group of Texas music luminaries in town to celebrate the 44th anniversary of legendary singer and artist Terry Allen and his wife, Jo Harvey Allen. The Allens, along with Robert Earl Keen, Guy Clark, Joe Ely, David Byrne (the token non-Texan), and a bunch of others ran around town during the day and stayed up drinking and playing music with the locals until 5 a.m. They played two rollicking shows at Ray’s Bar, with the $10 cover going to the clinic.

As Will Sexton warbled in the far corner of the bar, Wanstrom philosophized about the clinic. “This community owns this clinic,” she shouted over the din. “Our goal is to empower people because they are our directors. Everyone should be able to get health care, everyone.”

Terry Allen took over the microphone at the back of the room. He told a lame lawyer joke and challenged every attorney in the room–which at that point included criminal defense superstar Dick DeGuerin, Houston class-action lawyer; Marfa bookstore owner Tim Crowley; the county attorney; and others—to match the take at the door. The crowd caterwauled its approval.

“This clinic is for the people and by the people,” said Wanstrom. “It’s affordable health care. We work within our broken system, and we’re working to maximize our own health care.”

There is another hurdle: Finding a full-time doctor for Marfa. The clinic has been in touch with Dr. Adrian Billings, a Fort Worth physician who wants to open a practice with the community clinic after he finishes an obstetrics fellowship next July. Now the clinic is so full, there’s no room for him. Clinic directors have raised the idea of taking over the lease on the building that housed the former Rural Health Clinic. If no space can be found, Billings said he’ll open his practice in Alpine. But he wants to be in Marfa.

“I’m really proud to tell the story of Kate’s group and the wonderful, altruistic thing they’ve done,” Billings said from his home in Fort Worth. “It’s a great, community grassroots effort of people coming together and having a long-term goal. It’s a really neat thing.”

Back at Ray’s Bar, the party spilled outside at last call. In the back of the parking lot, Terlingua resident Butch Hancock hunched over a guitar playing song after song for a woman who stood nearby. All night, people had thumped Wanstrom on the back and asked her about the clinic: how it’s going and whether they’re going to get the funding from the hospital. She’s still amazed at the direct connection people have to their clinic—the one their friends and neighbors helped make happen.

“They wanted something better for themselves,” she said. “They did it.”

Sterry Butcher is a reporter at The Big Bend Sentinel in Marfa.