When Health Care Is Far From Home

The biggest barrier to treatment for residents of a tiny town in the mountains of Northern California isn’t insurance coverage -- it’s distance.

By Daniela Hernandez, Kaiser Health News

HAYFORK, Calif. -- It’s Tuesday morning, half past eight and already hot, when the small bus pulls up to the community clinic. Most of the passengers are waiting in front -- an old man with a cane, two mothers with four kids between them, packed lunches in hand.

Two more arrive. A gray-bearded man with a pirate bandana steps from the shelter of his Subaru. A sunken-cheeked woman rushes up on her bike.

“Woohoo! We have a full car!” the driver says brightly after they’ve all climbed aboard. The riders smile back, some with a hint of resignation. It’s time for the weekly trip to the clinic in Mad River, about 30 miles down a winding mountain road. The tight twists and turns are hard on the stomach, but even harder on the joints -- especially if you have chronic Lyme disease, as more than a few of these riders do.

Jeff Clarke is one of them. He acquired Lyme long ago from deer ticks that dwell in the region’s sprawling forests. But today he’s going to ask about a lump that’s been growing in his left breast. It’s starting to hurt, and he’s worried. His fellow riders list their own ailments matter-of-factly: asthma, dental decay, diabetes, drug addiction, heart disease and much more.

They wouldn’t be making this trip if they didn’t have to. In Hayfork, “we’re down to the remnants of the medical personnel,” says Clarke, 58, a well-spoken musician with a love for science and cats. “It just came to the point where if I needed to deal with anything important I just felt much more comfortable going over to Mad River.

Like so many American small towns, Hayfork has lost its vitality and much of its youth to bigger places. Nestled midway between Redding and Eureka, it’s not near anything. Even Weaverville, the tiny county seat, is 45 minutes away. There are no retail stores, theaters, museums, fancy restaurants. What the town has is star-filled skies and tree-lined ridges.

“We were all just fine with that,” says Shannon Barnett, a 41-year-old a former school teacher who grew up here. “Now it’s different.”

She’s referring to the dearth of basic health services.

There’s a local clinic but it’s staffed by doctors who rotate in from Weaverville once or twice a week, and otherwise it’s run by physician’s assistants. There are no hospitals for miles.

The Mad River clinic is bigger than Hayfork’s and offers a wider array of services but Clarke says it’s so backed up with patients it can take weeks to get an appointment.

In 2012, according to state data, there were 11 medical doctors practicing in all of Trinity County, roughly one per 1,200 residents. Statewide, the ratio is closer to one per 300. Specialists like dentists and psychiatrists are nearly non-existent in the county.

A county behavioral office offers counseling in Hayfork, but a counselor isn't there every day and sessions are by appointment only. Sometimes the most expedient treatment comes in jail -- Clarke calls it the “nudge from the judge.”

He mentions an acquaintance named Robbie, who suffers from paranoid schizophrenia. Since being released from jail, he’s been off his meds, Clarke says. He walks up and down Hayfork’s main strip, muttering to passers-by about the many people who are after him.

In these tiny towns of California’s far north, lacking insurance is not the biggest obstacle to care. Most people are insured, a good number are on Medi-Cal.

What’s ailing these people is geography – that, and poverty. The median household income in Hayfork is about $34,000 a year, well below the statewide figure of about $60,000,.. Unemployment is extraordinarily high – estimates range between 9 and 26 percent. Many people lack a sturdy car to drive, or even money for gas.

In the federal government’s parlance, Hayfork is a “medically underserved” community – one of 170 in California and roughly 3,500 in the country.

By definition, these areas have too few primary care providers, high infant mortality, pervasive poverty or a significant elderly population. Some medically underserved areas are islands of deprivation within otherwise well-stocked urban areas. Others are dots on the map like Hayfork, far from where doctors and medical services are clustered. According to the National Rural Health Association, only about ten percent of physicians practice in rural America, where nearly a quarter of the population lives.

For Hayforkers, health care is available – just on the other side of the mountain. “The problem, says Greg Schneider, a 65-year-old writer and band mate of Clarke’s, “is getting there.”

Lumberjacks and Janes

For decades, Hayfork had been fortunate. Well after the rise of urban health systems and their intricate business arrangements, it had a tight-knit local “system” founded on the simple, generous commitment of two people: a general practitioner and a pharmacist.

“He was everybody’s doctor,” Barnettsays of Dr. Earl Mercill, a GP who moved up from the Central Valley almost 50 years ago. “You never thought about going to anyone else.”

Mercill moved his large family to Hayfork in 1967 on a friend’s recommendation. It was still a mill town then, filled with lumberjacks and Janes, as the women were known, though it also had restaurants, shops and even a thriving art and music scene.

They built a house and settled on 40 acres. Mercill opened a clinic downtown.

He was beloved almost from the beginning. He made house calls -- sometimes walking over precariously narrow log bridges or shuttling to his patients’ homes by snowmobile. He delivered babies by flashlight after storms knocked down power and waited by his patients’ bedsides for hours, sometimes charging little more than a slice of cake.

“If they didn’t have any money, I saw them,” recalls Mercill, who’s now 91 years old. “If they could pay later, fine." If they didn’t, they didn’t.”

In 1982, Gerry Reichelderfer, a genial pharmacist from Marin County, came up and fell in love with mountain life. He took over the drug store next to Mercill’s clinic.

Reichelderfer lived just seven minutes and a single stop sign away from his shop. He’d open up anytime people needed a prescription. If they couldn’t pay right then, he’d put it on an I.O.U.

The men joined forces, talking daily by intercom. The partnership would last nearly two decades.

Mercill officially retired in the late 1990s, though he kept seeing patients for some time afterward. The town dedicated a clock to him in the square.

Eventually he sold his clinic to a doctor based in Weaverville. That doctor recently sold it again, to a district hospital.

“It was like a limb being cut off,” Barnett says of Mercill’s retirement. “I know at first I didn’t have another doctor for a long time. Other people didn’t either.”

A Turn of Fortune

After Hayfork’s mill closed in the early-1990s, the town's population -- never higher than the low thousands -- dwindled. Homelessness, poverty and drug addiction took hold.

Clarke, a runaway and hitchhiker in his youth, was in some ways typical of Hayfork’s new generation. He arrived in the 1980s, in the clutches of methamphetamine addiction, a habit he picked up in the bars where he played guitar. For years, he landed jobs and lost them -- working as a wood chopper, sandwich maker and cabinet craftsman. He started seeing a woman he met in rehab, then split with her, but not before they had a daughter. They named her Stormy Brooke. He gained custody and lost it more than once.

The 12-step meetings at Hayfork’s Solid Rock Church saved his life, he says. He goes every Monday and has been sober 10 years.

His health is ok, considering. He lost his teeth. His bottom denture wore out long ago and his top one is breaking. He has high blood pressure and hepatitis C, plus the Lyme disease that became chronic because it wasn’t treated right away.

Clarke lives in a two-room trailer next to the town cemetery. Supported by $889 a month in disability insurance, he spends his time organizing 12-step meetings, reading and volunteering as a sound engineer at a local coffee shop. On good nights, he gets paid a little. He wants to stay as healthy as possible, hesays, so he can look after 23-year-old Stormy and her 2-year-old son, Tony, who lives with his dad.

Stormy Clarke, a tall beauty too insecure to know it, cuts herself and has made several attempts at suicide. Her porcelain arms bear the scars.

“She has no self-esteem,” Jeff Clarke says. “She has no faith in love, or trust for any other human beings. She has some real darkness inside her, you know? I’m sure I’m responsible for a majority of that.”

Stormy Clarke has tried to get help, she says, but it's only sporadically available and hasn't helped much.

In June, during a fight with her father, Stormy had what Jeff thought was a stroke. En route to Redding in an ambulance, she started seizing so they put her on a chopper. At the hospital, the doctors said she’d had a stress-induced seizure.

After three hours, the doctors released her with a prescription to control her seizures and panic attacks, and told her to follow-up with her primary care physician.

“I had to laugh,” Jeff Clarkesays. “We’re in Hayfork!”

Back on the Bus

After the bus pulls into the Mad River clinic -- a remodeled blue cottage that used to serve as the local forest service office -- the riders start their wait. They are used to it by now: The kids pull out games and books; the adults chat in the waiting room or by a weathered picnic table on the back lawn.

Everybody has to be seen before the bus can head back.

On this day, Clarke is among the first in line. The physician’s assistant on duty examines his chest lump and advises against a biopsy, an invasive procedure, because he wants to run more tests. Clarke takes the news with some concern.

“I was pretty freaked out. I went in there with the agenda of the biopsy. They wanted to explore other options,” he says afterward.

By the time the bus gets back to Hayfork, it’s mid-afternoon. He drives back to his trailer, frustrated and spent.

A few Tuesdays later, he takes the bus back to Mad River and is referred to a specialist in Weaverville.

It is another two months before he learns the lump is a side effect of the medications he’s taking -- a hypothesis he’d mentioned earlier to physicians and their assistants in Hayfork and Mad River

Now he has to start thinking about replacing those dentures, which means another bus trip -- or several – around the mountain.

The Final Loss

Reichelderfer, 82 and in failing health, began looking for a buyer for his shop last year. Even the independents weren’t interested. Pharmacists’ family members didn’t want to move to Hayfork, and his business model wasn’t working.

Always generous about cutting patients like Clarke a break on payment, he wasn’t recouping enough from insurers. The clinic next door, Mercill’s former base, was referring patients to Weaverville.

With great sadness, he shut his doors on Sept. 18.

“I wish I could have been able to sell it to somebody,” he says, “for the convenience of the people."

From now on, Hayforkers will havto e to get a ride to Owens Pharmacy in Weaverville or Wal-Mart or CVS in Redding.

It took only a few days to board up a drug store open for 32 years.

It’s a relic now, standing just yards from the clock the town dedicated to Mercill, with his years of service gratefully memorialized on a plaque. 

Heidi De Marco and Carol Eisenberg contributed reporting.