It was a Sunday morning, already on its way to becoming the hottest day of the year, and the Alamo flea market, or pulga, was crowded. I wandered through aisles filled with people packed shoulder to shoulder, past vendors hawking everything from vacuum cleaner parts to a baby alligator. Next to a barbershop and an Affordable Care Act (ACA) enrollment center, I found it — a hand-lettered, neon-orange sign reading, “Previene la diabetes.”
The clinic’s baby-blue waiting room was stifling hot, and full. Patients sat in flimsy plastic chairs, a line of strollers alongside them, waiting to be seen by one of the public health students who serve as clinic attendants. Behind a desk, the supervising physician, Dr. Brian Wickwire, sat thumbing through a collection of academic papers he’d printed for me. “Everybody loves the pulga,” he said by way of introduction.
After 12 years as an internist at a low-cost federal clinic, Nuestra Clínica del Valle in San Juan, he grew exasperated by the sheer volume of serious, diabetes-related illnesses — blindness, gangrene, kidney disease — that could have been prevented with access to routine primary care. After venting his frustration during a class at the Texas A&M Health Science Center in McAllen, a group of public health master’s students offered to help. Hence, the building blocks for the pulga project, known officially as the Prevention of Diabetes & Dialysis Through Education and Resources. Launched in November 2014, it is among several new projects aimed at checking the spread of a devastating, expensive, yet fully preventable disease in the Rio Grande Valley. “We test for diabetes in real time,” explained Wickwire, a graying man in his early 60s, notable for his earnest manner. “And then we try to expedite them into the health care system before it’s too late.”
Diabetes and its complications have reached epidemic proportions in the Valley. A major study begun in 2003 by the University of Texas School of Public Health in Brownsville found that 30.7 percent of 2,000 randomly selected Valley residents tested positive for diabetes. An alarming 50.3 percent of those had not been previously diagnosed. The results are a logical outcome in a region where 80 percent of the population is overweight or obese, the per capita income is half the national average, and more than a quarter of residents are uninsured, despite the ACA’s enactment. Another study by the University of Texas Health Science Center at San Antonio projected that as much as $82.8 million is spent every year on hospitalizations due to preventable complications from diabetes.
The structural challenges to reversing the Valley’s tide of diabetes begins with Texas’ refusal to expand Medicaid — an estimated 1 million Texans fall into the “coverage gap” — and the failure of the ACA to address health care for undocumented immigrants. Nonetheless, Wickwire and the clinic’s public health students are part of a cohort of medical professionals dreaming of turning the Valley’s challenges into an opportunity for research and innovation, especially in the most underserved areas. The question is whether the efforts are too little, too late for a health care system in critical condition.
At the pulga clinic, Melissa Lopez, a first-year student, led me behind the curtain, where she was attending a man in his late 40s. An agricultural worker, he wore a wide-brimmed hat, black boots and a white shirt unbuttoned halfway down. Lopez measured his height and weight, then quickly pricked his finger. “Es todo,” she said, handing the sample to the lab technician.
As they waited for results, Lopez asked him about his diet and exercise, and reviewed the Harvard-generated Healthy Eating Plate food choices, a replacement for the more carb-heavy Food Pyramid. They agreed on an action plan: walking at the elementary school by his house and eating more vegetables. She read him his lab results — he fell into the pre-diabetic range. He agreed to come back in three months (a receptionist would call and remind him). Then he left, returning to the heat and crowds. “The most basic, simple primary care — what these students do — is the key to confronting the diabetes crisis,” Wickwire told me.
If detected early, diabetes is relatively easy and inexpensive to manage, even reversible in some cases. At the pulga clinic, patients found to fall into the diabetic range receive a call the next day. They’re offered a same-day appointment for as little as $25, which is the first step toward providing them with regular health care. For many of them, though, time has run out. About 40 percent of the patients screened so far at the pulga clinic have kidney disease and likely will be on dialysis in three to four years. “Once they get to this point, there’s no stopping it,” Wickwire said.
And while the clinic screens about 25 people on a given Sunday, as many as hundreds of thousands of diabetics in the Valley go untreated. “It’s just a drop in the bucket,” Wickwire said. “We need to reach these people, and we need to make it, if not free, then as affordable as possible. And we need to go to them. Not wait until they show up in the ERs.”
If community outreach and primary care for the uninsured save lives and money, why aren’t we doing more of it in places like the Valley? The answer lies partly in the thorny politics of health care reform and immigration policy. But there’s also a simple human resources problem — too few doctors. By some estimates, the Valley has 54.6 primary care doctors per 100,000 residents, compared to an average of 69.5 in Texas. And not enough of them are like Wickwire, willing to work for a fraction of what they could make in a standard hospital; one of Nuestra Clínica’s greatest challenges, CEO Lucy Ramirez Torres told me, is recruiting and retaining doctors.
The new University of Texas-Rio Grande Valley (UTRGV) School of Medicine attempts to address the shortage. Established by the Texas Legislature in 2013 in a move that required merging two UT campuses 70 miles apart, the medical school welcomed its inaugural class of residents over the summer. At the John Austin Peña Memorial Center, located near the medical school’s Edinburg campus, I met with Dr. Eron Manusov, clinical and department chair for family and community medicine, and two new residents, both wearing pristine white coats emblazoned with the UTRGV logo.
“The focus is on community and populations, especially the underserved,” said Manusov. “We are changing health care delivery for the future. It will be about team-based medicine. Quality, not quantity.” He’d invited me to the Peña clinic to demonstrate how its interprofessional teams serve teenagers who have been triple-diagnosed with physical and mental illnesses as well as addictive disorders. The teens see social workers who coordinate care provided by primary care doctors, psychologists, even GED teachers, all under the same roof. The practitioners meet every two weeks to agree on a treatment plan and assess progress. The idea is that they share valuable treatment insights while avoiding redundancy.
The interprofessional approach was recently highlighted by surgeon and writer Dr. Atul Gawande. In the New Yorker in 2009, he’d penned a scathing critique of the profit-maximizing medical culture in McAllen. The piece was required reading for cabinet members in the early Obama administration. In a follow-up visit to McAllen, Gawande found that an ACA-era shift from a pay-for-service to a pay-for-quality reimbursement model reduced McAllen’s health costs by a half-billion dollars, as doctors adopted time-consuming but evidence-based practices such as spending more time with patients and working collaboratively.
For Manusov, interprofessional teams are a snapshot of what he hopes health care will look like in the future. “Eventually, we’ll have [UTRGV] School of Medicine clinics throughout the Valley,” he said. “We’ll have mobile clinics of interprofessional teams traveling to the colonias. We’ll have residents from all our primary care programs manning those clinics. Eventually, our graduates will take over these clinics and provide care based on the ideas of population health and reducing health disparities.”
It’s a compelling vision, but Manusov is candid about the obstacles to realizing it. The medical school must reverse generations of brain drain from the Valley and convince those who stay to work in primary care for underserved populations. To that end, UTRGV has focused on recruiting students with Valley ties and a demonstrated commitment to service. It has implemented early-admission programs for high school students, and has even taken a page out of the college athletics playbook by recruiting in middle schools.
One of its new residents, Dr. Marco Escobedo, is from Eagle Pass, a four-hour drive away. He went to medical school in Guadalajara and volunteered at a clinic outside that Mexican city. “One of the factors that drew me here is the mission to serve the underserved,” he said. “And it’s close to home.” Another resident, Dr. Charles Lewis, drove a Budget truck to the Valley from coastal North Carolina, where he grew up. Both residents’ first rotation was in the ER of a McAllen hospital, and for Lewis, the experience was a shock. “Back home, I’d see really acute things, people coming off the helicopter and things like that,” he said. “Here, I’m seeing stuff from colds to very chronic issues — patients who really should be followed by a primary care doctor. You have dialysis patients using the ER for their dialysis.”
On the other end of the Valley, at UTRGV’s Brownsville campus, scientists are combatting the Valley’s diabetes epidemic at a level even more elemental than primary care. In an immaculate room at the South Texas Diabetes and Obesity Institute, there are two genome sequencing machines, each worth about $750,000. “This is basically a mansion on a table,” geneticist John Blangero said in reference to the machine’s cost. The lead scientist for the institute, he is an intense but gregarious man with salt-and-pepper hair that spills over his shoulders. The machine, the size of a large copier, can catalogue an individual’s entire genome. “It took a decade to do the first human genome,” Blangero said. “Now, we can do it in our own lab in six days.”
The institute represents a major investment in basic research by UTRGV. Before its move to the Valley this spring, the institute, which has garnered more than $200 million from the National Institutes of Health since 2000, operated in San Antonio. The institute’s director, Sarah Williams-Blangero, who has worked there alongside her husband for 30 years, told me that its research group of 22 scientists was attracted by the UT System’s resources, but also because their research is so relevant to the Valley. “With so much of the population suffering from diabetes,” she said, “it’s a chance for research to really have an impact on the community.”
The institute’s projects run the gamut from lifestyle intervention studies to brain imaging. One study involved putting subjects under an MRI and feeding them milkshakes; scientists wanted to look at the part of the brain responsible for appetite and satiety. But its most ambitious undertaking is a long-term genetic study of more than 3,000 Mexican Americans who are part of large, extended families in San Antonio and, now, the Valley. Families with deep roots in one place, Blangero explained, are vitally important for genetics research. “Genetics is all about the transmission from parents to offspring,” he said. “When we get these very large families, we can follow the bits of DNA, and correlate them with the risk of the disease. Making sense of this data is kind of where the ‘eureka’ moments appear.” His “eureka” moments are the discovery of rare genetic variants that occur within families and either lead to developing diabetes or provide protection from it.
After walking through elegant archways and past courtyards with gurgling fountains and native plants, we arrived at the biorepository, 28 industrial-size freezers set at minus 80 degrees Celsius to preserve the country’s largest collection of Mexican-American genetic material. Eventually variants identified from these samples could lead to new genetic targets, with potential to dramatically speed up drug development. At the back of the room, Blangero led me to five washing machine-size steel cylinders, attached by a hose to a liquid nitrogen canister. The deep-frozen stem cells inside could be turned into any kind of tissue in the human body, allowing his team to probe more deeply into the cellular basis for diabetes. This is the work that most excites him. “It will help us understand what the real cause is,” he said. “There are potential cures down the road. Certainly, I expect juvenile diabetes to be cured.”
The toll that the final stages of kidney disease take on the body is painfully evident even from a distance. Claudia, a 34-year-old mother with end-stage renal disease (ESRD), was waiting in the doorway of her tidy brick house in Mission when I pulled up, accompanied by Milena Melo, an anthropology Ph.D. student researching the illness. Claudia is blind in one eye and has lost all of the fingers on one hand. Her skin color is difficult to describe. After we sat down in her house, Melo remarked on a framed wedding portrait on the wall. “I was blanca, blanca, wasn’t I?” Claudia asked. “Now, I look at myself, and I see… purple?” She studied her arm. “I don’t know what color I am anymore. Green?”
Claudia is one of approximately 400,000 Americans receiving dialysis for ESRD. The vast majority of them receive routine, life-extending dialysis three to four times a week, paid for by Medicare. But for Claudia — and most other undocumented immigrants with ESRD, including 200 who live in the Valley — the story is different.
As a girl in the border city of Reynosa, she was diagnosed with Type 1 diabetes, the genetic form that accounts for only 5 percent of diabetics. She managed the disease on her own until she unexpectedly became pregnant. After giving birth to a daughter, she began retaining fluid, including in her lungs. “I began waking up at night not being able to breathe,” she said. “I felt like I was suffocating. I wouldn’t sleep all night. That’s when I began going to see Dr. Wickwire at Nuestra Clínica.”
The morning after her first visit to the clinic, she was called and told to come in right away. “I got there, and they said, ‘Ay, pásele.’ That’s when I knew it was bad. They never do that; it’s always a whole dog-and-pony show before they see you.” Wickwire told her she needed to go to the ER immediately. Her levels of potassium, which regulate the heart and can cause congestive heart failure if too high, were off the charts.
At first, she received dialysis twice a week at the hospital’s ER, and even though standard treatment calls for three to four sessions, she slowly felt better. Then she was told that the hospital, handling a sharp increase in ESRD patients, could no longer afford even scaled-back treatment. Now, like the majority of undocumented immigrants with the disease, she has to wait until her potassium levels provoke cardiac arrest. “When my potassium gets too high,” she told me, “the first thing is my heart. Then my feet and my arms won’t react. My head won’t stay up. But most of all, my heart just feels like it’s going to burst.”
Under the 1986 Emergency Medical Treatment and Active Labor Act, hospitals must treat everyone in emergency medical circumstances, regardless of their immigration status or ability to pay. But the definition of an emergency has been left up to states and in some cases individual communities. New York, California and North Carolina use Medicaid and other sources to finance regular dialysis for patients without immigration documents, reasoning that they would die in a matter of weeks without it. In most other states — including Texas, with the exception of Houston — patients must be in the process of dying to receive government-financed treatment.
In the fall of 2000, Dr. David Sheikh-Hamad, chief of renal services at Houston’s Ben Taub Hospital, saw an opportunity in what was then the hospital’s decision to stop offering routine dialysis to undocumented immigrants. He used it to launch a study of the results of regular sessions versus emergency dialysis. The study’s first finding surprised no one: Patients who received emergency dialysis reported greater physical pain and worse overall health. The second finding, though, was extraordinary. The average health care costs for routine dialysis patients were $76,906 a year, compared to $284,655 for emergency dialysis patients, largely because the latter spent more time in the hospital for life-threatening complications.
Sheikh-Hamad used the study to convince Harris County to open a dialysis center for undocumented and uninsured patients. Melo hopes that her research might someday spur a similar transformation in the Valley. For now, though, Claudia’s only option is the ER. So she has to pick her poison. If her potassium levels aren’t sufficiently elevated, the ER sends her home without dialysis. Without treatment, her lungs retain fluid and she gets pneumonia frequently. With that in mind, she drinks a glass of potassium-rich V8 juice before leaving for the ER. She prefers the risk of dying from a potassium-induced heart attack in the hospital over suffocating in bed at night.
“The nurses will tell me, ‘Don’t do that!’” she said. “But if I don’t do it, I won’t get dialysis. If I could just get dialysis two times a week, I would be OK. I know it’s expensive, but I would be OK.”