Reining in rural Imperial County’s healthcare disparities

The story of how Hugh Kessick found himself in an air ambulance soaring toward the trauma center at the UC San Diego hospital starts with what seemed like an end. Just a few minutes before he had been helping his friend move heavy equipment, but then he fell and slammed his head on the steel deck of a trailer and was out cold, eyes open, not moving.

“I was bleeding pretty bad… I was gone,” Kessick said.

The next thing he remembers is being rolled into the helicopter, snapped into position, the nurse jumping in, flanking him to his left and then they were airborne. The 45-minute flight to San Diego carried him across the desert and over the Laguna Mountains. With no trauma center in the county equipped to deal with injuries like Kessick’s, air ambulance services are a lifeline for residents.

As the region braces for what many see as a transformational expansion of industry to be ushered in by the discovery of lithium in the Salton Sea, with thousands of workers to join the ranks, some residents worry the medical system is already strained as it stands. They fear the profit will not trickle down to improve access to critical resources such as healthcare and education.

Even when rural areas may see an uptick in industry, healthcare for locals rarely improves, said Norris Gunby, a professor of Health Services Administration at USC. Without the amenities to attract upper middle class workers with college degrees, industry growth often relies on services in nearby cities. Qualified and better paid workers will often choose to commute, and those earning less join the fabric of healthcare as its stands.

Imperial County’s unemployment rate is the highest in the state. The county ranks third lowest for primary care physicians per capita in California. It is an outlier by numerous percentage points to both state and national averages in key quality-of-life indicators, including diabetes and cancer rates, the number of children living in poverty and drug-related deaths. Roughly 15% more of its residents rely on public insurance coverage in comparison to state averages.

Brawley is home to state-funded Pioneers Memorial Hospital, a level IV trauma center and the county’s most advanced facility. When it comes to emergency services, only one designation is lower than that. This means residents must travel out of the county for many emergency services – if they have a way to get there.

Advocates Eric Reyes and Isabel Solis of Los Amigos de la Comunidad relax after the Cattle Call parade at Chabela’s Restaurant in Brawley on Nov. 12, 2022. (Photos by Philip Salata)

It also means that for life-saving procedures, patients often rely on helicopter ambulances to bring them to trauma centers beyond the county. For some, that option would not even cross their mind. As helicopter ambulance nurse Andrew Murphy described, it could be life-saving, but also financially life-altering for some.

Activists like Eric Reyes of Los Amigos de la Comunidad are fighting on the community's behalf, not only to channel lithium profits into the community, but also to overturn years of upset and doubt fueled by having been left out more than once.

To counteract that, California assembly members pushed through a tax on lithium of which Imperial County will receive 80%. With this tax made a reality, Reyes sees a path toward a different future. The passing of a tax of this kind, preceding the development of an industry, is a change from the way things unfolded in the past.

“Now we have a base from where to start,” Reyes said.

Air Ambulance: a last resort, but for whom?

Erik Hiraoka came to Imperial Valley from Michigan. It was about a girl. It didn’t work out. But he stayed and now he has a family. He is a flight paramedic with REACH Air Medical Services, one of the bigger “helivac” companies in California. It was the first to establish services in Imperial County and that was its station in Southern California. Now it has three stations there.

Hiraoka provides an essential service to the county of Imperial, but one that also points to what essentially is missing in the healthcare system – emergency healthcare services for trauma patients.

Erik Hiraoka poses in front of the REACH Medical helicopter he had just exited after a call out to the Glamis Dunes. (Photo by Philip Salata)

Hundreds of patients yearly are helicoptered to neighboring counties for critical healthcare needs in the valley.

Another “helivac” nurse, Andrew Murphy, has a layered take on his work. He sees how critical it can be. He respects the safety protocols and the way his team works. After years of work, he still speaks in awe of flying above mountains and forests, while helping residents living in remote locations. He also does not take the service for granted.

“It's a very interesting business model,” Murphy said. “it's something that to me doesn't make a lot of sense. You're spending millions of dollars on aircrafts and all this stuff for maybe getting a call.

“It’s definitely not a given.”

Costs for air ambulances vary vastly. They can start at $15,000, but since the COVID-19 pandemic, twists and turns hit the market. Patients have been surprised with bills of over $50,000. How that affects patients varies, depending on their insurance. In a county like Imperial, these barriers can heavily influence a patient’s decisions.

During the pandemic, often patients did not have a choice. Reyes recounted how quickly the healthcare system reached capacity and how it took longer than other areas in the state to return to normal levels. Lacking access to preventative care, residents often rely on emergency services to resolve health issues that could have been avoided, further straining the system.

Meanwhile residents are not the only ones drawing on the helivac resources. According to Brenton Lopez, a director at REACH, the team spends a significant amount of time rescuing recreational off-road riders from nearby dunes. ATV and dirtbike injuries not only heavily tax the local healthcare system, but also occupy “helivac” staff.

CalEnergy has a prominent seat at the table

CalEnergy, a subsidiary of Berkshire Hathaway, Warren Buffet’s venture into lithium extraction in Imperial Valley, summoned the air ambulance services numerous times for critical jobsite injuries, court records show.

Some employees at the geothermal plants work around equipment that reaches over 700 degrees fahrenheit. Burns are frequent. Imperial Valley does not have a burn center. Burn victims have to be flown out to San Diego.

If all stakeholders realize their plans to build out what is now being referred to as the “Lithium Valley,” the region could see an influx of thousands of workers, and with that the inevitable rise of workplace injury.

With medical resources as they stand, this would put a further strain on the healthcare system.

But companies and local subsidiary stakeholders have been pushing back against the recently passed lithium tax which would allocate money for building out infrastructure benefiting the community. Their argument is that it will deter business, and slow down development.

Reyes is among those who advocated for the lithium tax, and knows that he will have to continue to advocate as stakeholders look for ways to avoid the costs. He is working to make sure the money gets to the communities that will be immediately affected by the development.

“That’s who's going to take the brunt of it,” Reyes said.

With the environmental impact report yet to be released, he is worried about the future. He celebrates the tax as a way to help bolster the community against the many unknowns.

“They create these illusions [of safety] and then later they have to go back and retrace their steps,” Reyes said. “How many times have we found out 40, 50 years later, and then those guys try to make reparations. But by that time those guys will be gone, they got their billions. It’s historical, right?”

Announcers at the Cattle Call Parade call out to the audience from the back of a pickup truck in Brawley on Nov. 12, 2022. (Photo by Philip Salata)

A kaleidoscope of factors

Among the many roles they play in their community, Reyes and his colleague Isabel Solis are healthcare advocates under Los Amigos de la Comunidad. They see healthcare as an ecosystem shaped by access to other critical resources such as education or transportation. When the two described access to health services in the rural border region, what takes shape is the image of Escher’s countless staircases leading into brick walls, or descents back to other basic problems.

“First thing you need to understand is in an area with the lowest per capita income,” Reyes said, “and a lack of full-time good paying jobs with full benefits, there's always going to be health disparities.”

On top of her work as an advocate, Solis is also a board member at Imperial Valley Community College and an elementary school teacher. Her real-world experiences show how interconnected all these issues are, and drawing on them, she insists that education is a key factor in economic mobility. But being able to follow that path depends on even more factors.

“If a student wants to make it to Imperial Valley College from Niland (a northern municipality in IV) for an 8 a.m. class,” Solis said, “they have to catch the bus at 6 in the morning. That’s two hours one way.”

“What if they have a family?” Solis went on to ask. Imperial County teenage pregnancy rates are one of the highest in the state.

“It’s a snowball effect,” Reyes said.

On the level of insurance and funding for healthcare infrastructure, a similar pattern exists. More than half of Imperial Valley’s residents rely on public insurance coverage through Covered California. But not everyone qualifies, and many fall through the loops. Whether they be undocumented, or have an income just above the cut, they may be struggling due to a variety of factors.

Those who do not have coverage often rely on clinics for health emergencies. Reyes said clinics were established to fill the gap for the uninsured. They end up taking in those who need basic healthcare but under the pretext of an emergency visit. Clinics are not equipped to deal with trauma patients, neither can they provide the preventative services that long-term healthcare requires. And yet clinics in Imperial have a more stable economic platform because they are able to write off many of their expenses to the state and federal government.

Reyes went on to point out what to him seemed like an irony: Pioneers hospital on the other hand, a public entity, does not fall under the same funding avenues. The hospital struggles to maintain proper staffing, or to build out missing critical resources.

“They may be reducing down the (cancer) department while we have the largest cancer rates in the nation,” Reyes said. Reyes has colleagues who work in the hospital, and his insights reflect that.

Some employers in the region offer healthcare plans through Sistemas Medicos Nacionales, S.A. de C.V. (or SIMNSA), which requires subscribers to cross the border into Mexicali for most healthcare needs. It’s cheaper for employers, and for some it's easier to navigate than U.S. public healthcare.

All these factors also affect prospective employees considering moving to Imperial County to work in the healthcare system. Students aiming to work in the medical field who find their way out of the county most often choose to stay out.

According to Ellen Pollack, chief information officer at UCLA Health, staffing is a major issue in the healthcare landscape, especially at smaller hospitals. The COVID-19 pandemic exacerbated the problem. Yet for major health centers like UCLA, which have the name and standing, staffing is not an issue.

“But small hospitals,” Pollack said, “likely can’t even find critical care nurses. And even if they have 100 beds in their hospital, maybe they only have staff for 70 beds, and then they're at full capacity. So there's no way they can handle a trauma and they send them out because of that."

Reyes points out that this also affects the quality of healthcare, not only because of staffing shortages, but also because good healthcare also relies on how medical staff relates to the community. With current staffing issues, language barriers often inhibit patients from fully using existing resources. Or if patients are used to a certain physician who leaves, that bond is broken and it may be difficult to reintroduce them into the healthcare system.

And that’s where Reyes and Solis put their focus – building relationships with people throughout the community of Imperial Valley. “Each community is different.” Reyes said. “They have people they listen to and we have to outreach and gain their trust.”