We returned to rural Arizona for our American Futures project this spring. During our travels, we have visited a number of towns that could easily be called rural: Eastport, Maine (pop. 1,300), far down-east and a mile across the strait from Campobello Island, and Chester, Montana (pop. 850), 40 miles from Canada, vie for being the smallest.
Ajo, Arizona, one of our favorite towns, is slightly bigger. About 2,300 people live there throughout the year, and the numbers swell to almost twice that when the snowbirds arrive from the states that border Canada. Many winter residents arrive in their RVs or campers, and others settle into charming stand-alone small houses. By snowbird standards, Ajo is very affordable.
Ajo is about a two-hour drive south of Phoenix, a two-hour drive west of Tucson, and just about 40 miles north of Mexico. It is surrounded by federal lands. The reservation of the Tohono O’odham Nation lies to the east of Ajo; it is home to 30,000 residents and is the size of Connecticut. The Organ Pipe Cactus National Monument is a vast park to the south and the Cabeza Prieta National Wildlife Refuge is to the west. The 40-mile drive north to the closest town of Gila Bend through sparse desert, with hill and mountain views in the distance, is considered just a hop up the road.
This is beautiful country, and it is remote. To put it in our city-folk terms: While in Ajo, we had no cell coverage and the nearest car rental I could find was in Phoenix.
I wanted to get an idea of what rural health care means in a town like Ajo, so I visited the Desert Senita Community Health Center, which serves Ajo’s residents. The center (pictured above) is located in the buildings of the former dormitory for single men who worked at Ajo’s New Cornelia copper mine. The mine made Ajo into a thriving company town during the 20th century. That high-wage, steady-job era lasted until the mine shut down in 1985. There was a hospital back in the mine’s heyday, which stands vacant now just uphill from the downtown plaza. We heard a rumor that someone may buy it.
Today, the nearest hospital to Ajo is about 100 miles away to the northeast, in the town of Casa Grande. This is a consideration for Ajo’s elderly. You wouldn’t move to Ajo if you anticipated the need for regular, quick, serious medical care beyond what the clinic can offer. (There is a hospital a little closer, in Sells, about 70 miles from Ajo, on the Tohono O’odham reservation; however, it is designated for tribal members, although it does receive non-tribal patients in emergencies.) With critical cases, Ajo’s ambulance service heads for Gila Bend, radioing ahead for a medevac helicopter to meet them there. (We landed our plane at Gila Bend rather than flying on to Ajo on our first trip because of the extreme flight restrictions for the A10 practice routes inside the Barry Goldwater Bombing Range, which occupies the airspace between Gila Bend and Ajo.)
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Distance matters for what most of us think of as routine care. Jane Canon is a registered nurse who has been at the clinic for 16 years and is now its manager for quality improvement and also for outreach to the community and beyond. She told me that since there is no way to get prenatal care in Ajo, many pregnant women choose to put off those examinations and checkups for a while. And many decamp to Tucson or Phoenix a few weeks before their due date.
Also, keeping specialists’ appointments outside of town can be cumbersome and stressful for folks with limited resources and limited experience navigating unfamiliar urban areas. Costs involve gas money or public transportation to and from Phoenix, plus a city taxi to the final destination, plus of course, a lot of waiting. For the center’s staff, a brief regional meeting for Pima County can eat up an entire day, with two hours drive each way to Tucson, the county seat.
On the other hand, being rural and being poor means the Ajo clinic earns the designation as a “Federally Qualified Health Center” (FQHC). This awards them enhanced reimbursements for Medicare and Medicaid patients. In Ajo, roughly one-third of the population is on Medicaid, one-third on Medicare, and the rest is on private insurance or they self-pay. There is also a sliding scale of fees for those who fall through the cracks. The FQHC designation brings Ajo other benefits as well: advice and counsel for staff, equipment like a “crash cart” (a moveable cart equipped for emergencies), and extra personnel support, like a regularly visiting cardiologist and ophthalmologist.
The center provides enviable one-stop-shopping for many routine procedures that would have the rest of us traipsing all around town for multiple appointments: X-rays, lab work, a well-stocked pharmacy, a dentist, a certified Spanish translator, and a special phone line with third-party translators for multiple languages.
As Canon describes, because of its remoteness, the clinic needs to be “self-ready” for a lot of circumstances, from an ebola outbreak (unlikely) to back-up for massive power failures (more likely). The local high school is set up with water, cots, and an emergency generator for electricity and cooling. And a strong community of support is nearby, including folks from the nearby border patrol station from Organ Pipe and Cabeza Prieta.
The government extras come with extra paperwork as well, to make sure everything is in order and compliance. Even for an individual health care consumer, paperwork can be challenging; it’s easy to imagine what it means to an entire clinic.
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Each rural area has its own character. Ajo’s is marked in part by its heritage as a company town. And this affects its current health care in ways I found surprising.
The older population of Ajo grew up with cradle-to–grave services provided by the mine, from education (its beautiful schools), to entertainment (movie theater, skating rink, and holiday parties), to provisions (the company store), to housing, to medical care. The position and person of the company doctor was one who moved quickly, was always considered right, and did not broker a lot of questions.
Moving Ajo from its old-time habits into the modern era requires shifting that dependent mindset to one where people are encouraged to take charge of their own healthcare, including the planning for preventive and personal care, and a willingness to bring their questions into the center’s health care providers. The clinic tries to jumpstart this last effort by guiding people through three questions for them to keep in mind: What is main problem; What do I need to do about it; Why is that important?
I asked Canon about some of the worst problems for this rural community, and then without giving her a chance to answer, I guessed: drugs, alcohol, violence. She confirmed, and explained how these could spawn a vicious cycle of depression, lack of motivation, and could even contribute to obesity and type 2 diabetes. If you’re depressed and unmotivated, just getting up off the couch can seem like a major effort.
Breaking these cycles means fighting against stigma; getting patients to admit, confront, and take action against these issues in their lives is on the plates of clinic staff as well.
Breaking the cycle of obesity, especially starting with the youngest people in town, has been a focus of Desert Senita. Among students in Ajo, the Ajo Unified School District (AUSD) reported in 2009-10 an obesity rate of at least 32 percent in every grade. (The CDC reports that in the U.S. in 2011-2012, 20.5 percent of adolescents ages 12 to 19 years were obese, 18 percent of children ages 6 to 11 years.) Jane Canon and the Desert Senita Center were instrumental in developing the very popular Edible Ajo Schoolyard program (EASY), which I described in an earlier post here, designed to educate about and encourage healthy eating habits. Students work in the school garden, harvest some of the crop for the cafeteria, and sell some of the crop at the Ajo town market. Canon emailed me that by 2016, obesity rates have dropped between 1 and 11 percent among K-6 students, who are the ones participating in the EASY program. “Change is slow” writes Canon, but “we believe that the promotion of growing and eating healthy foods through the EASY curriculum (the edible schoolyard program) is fueling the change.”
Additional outreach programs from the center now number more than 20, including the Ajo Nutri-Bike coalition, an American Planning Association Plan4Health project that operates as a “sustainable cycling hub,” focusing on bike safety, maintenance, and cooperation with local health-based partnerships.
Jane Canon worries already about finding a replacement several years from now when she plans to retire. Staffing a remote medical facility has the same problems as staffing remote schools. That’s easy to understand; it takes people with a special commitment and dedication to practicing rural medicine. Those who choose it earn a precious reward; they make an invaluable impact on the lives of the rural residents in America.