HealthyCal.org

This section of tracks in downtown Fresno could one day lie next to California's high-speed rail line. City officials hope it would help revitalize Fresno's long-neglected downtown.

By Derek Walter

California’s high-speed rail project has the potential to revolutionize the state’s railways. A promise of a two-and-a-half hour journey from San Francisco to Los Angeles should tempt those tired of fighting clogged freeways or flight delays. But for the city of Fresno, the stakes are even higher.

The rail would link Fresno to the rest of the state, when the city has often been left off the map when it comes to travel options. San Joaquin Valley’s Interstate 5 was built to bypass Fresno as well as Bakersfield and Merced. Traveling to San Francisco from Fresno usually means driving, as there is no direct train route. Fresno’s airport has far less options than California’s larger cities. For a city that was born on railroad lines, it finds itself often disconnected.

California High Speed Rail Authority Deputy Director Jeff Barker said it is cities like Fresno that have the most to gain. Others are more guarded in their optimism as they watch the rail project develop and slowly start to change the city.

“A system like this will inject major money and has a positive impact on the economy. The Central Valley gets that more than the rest of the state,” Barker said. “They felt the pain of the economy more than other parts of the state.”

Craig Scharton, Fresno’s director of downtown community revitalization, sees the project as an essential component of changing that situation. The new foot traffic that a high-speed train station would generate could continue the rebirth of Fresno’s downtown.

Long neglected by developers, downtown now reflects some signs of growth. Its Triple-A baseball stadium, Chukchansi Park, saw season ticket sales increase by 20 percent this year. Other positive signs include the newly built Iron Bird Lofts boasting 100 percent occupancy, with another residential project nearby underway, Scharton said. A modern station, he said, would connect riders to a downtown with historic architecture that is ripe for growth.

“That is the best possible world, the character of the old; it’s where Fresno was really created,” Scharton said. “And it would connect us to the rest of California. It’s a pretty compelling story.”

The road to a finished project still has several stops. Last week the High-Speed Rail Authority board voted to remove miles of proposed elevated tracks, which city officials argued could have been an eyesore as well as too costly. The station location may also move further west to avoid conflict with existing rail lines. A draft Environmental Impact Report is due by the end of this summer.

Funding for the project primarily comes from Proposition 1A, which was passed in 2008 to provide $9.95 billion in bond money. Also, California recently applied for $2.4 billion in federal funds that was returned to the U.S. government by Florida.

The city hopes to celebrate groundbreaking some time in 2012, Scharton said. From there, it would likely be several years of construction before service could actually begin to either Merced or Bakersfield, he said.

A project of this scale could certainly change the dynamic of the neighborhood. For some of the tenants of a nearby building, it could change them quite dramatically.

The Academy for Civic and Entrepreneurial Leadership (ACEL) charter high school in downtown Fresno leases part of a building that would be incorporated into the new station. It occupies the site of Fresno’s original train depot, a historical fact not lost on Scharton and other city planners.

The current building is in no danger of being demolished or relocated, Scharton said, but it does have some following the site’s progress closely.

Dave Childers, the principal of ACEL, said he is hopeful that his school can continue to operate where it is.

“Like many others, we have serious concerns and grounds for those concerns,” he said. “We invested a lot of time, energy, and taxpayer money into securing our current location. Obviously, by signing a 10-year lease, we were anticipating a great deal of stability – which is a key to the overall success for a charter school.”

The train depot itself that would bring about such stability, Scharton hopes. For example, the site is only about a block from the baseball park that has sparked some, but not enough, life into downtown. In order to make the station a further driver of revitalization, the city must capitalize on getting travelers to spend their time and money there.

“Obviously more foot traffic and foot activity adds more vitality,” he said. “It definitely connects us to the major world powerhouses of the Bay Area and Los Angeles.”

The location is not the only concern. Assemblyman David Valadao, whose south Valley district includes Hanford and Bakersfield, said inconsistent cost estimates and a potential “detrimental effect” on agriculture are on his radar screen.

“I have yet to get a serious answer as to the costs of the project, they range from $60 billion to over $150 billion,” Valadao added. “When originally sold to voters, High Speed Rail supporters claimed the project would not require a taxpayer subsidy outside of the original capital investment. No one believes that will be the case now.”

Director Barton and others hope that with solid urban planning the impact on agriculture would be minimal.

“Around the world you see a smart land use pattern that promotes urban development around high speed rail stations,” Barton said, “so you end up protecting a lot of your agricultural land and open space because of the building patterns that happen around the stations.”

Next, the state legislature must weigh the Environmental Impact Reports as well as cost for service. While funding is available for construction, Barton said, the state still must decide how to fund running the system.

By Rosa Ramirez

California’s state prison population has remained stubbornly high over the past decade. The new Alameda County Chief Probation Officer wants to lead his department in a new direction, one that focuses on prevention. David Muhammad, an Oakland native, favors an approach that promotes incentives to good behavior, rehabilitation and alternatives to incarceration. These are the kinds of methods, according to Muhammad, that get the best results – fewer people in prison and on probation and parole.

“Basically, if we assess you to be low risk, we are going to leave you alone,” Muhammad said in a recent talk to journalists at UC Berkeley. “If the person is high risk, we want to provide services and opportunities, not just the old trail you, nail you and jail you.”

“I’m a reformer. The only reason I’m in this job is to reform and improve the system,” Muhammad added in an interview with healthycal.org after the event. “When I interviewed for this job with the board of supervisors, I told them if you want business as usual, do not select me.”

Muhammad was tapped for his position after the agency spent eight months without a chief probation officer. Donald Blevins, the former chief probation officer, left the agency in April 2010 to lead the Los Angeles County Probation Department, the largest probation office in the country.

Muhammad helms a department that has 2,000 juveniles and 15,000 adults on probation. Eleven thousand of those adults are without a probation officer because of budget cuts. The remaining officers are overworked – each one has caseloads ranging from 100 to 105 people.

“Obviously there’s very little supervision,” Muhammad said.

His challenge now will be to convince stakeholders that targeted supervision of the highest risk cases is the best use of limited resources.

Models that work

Since returning to the East Bay nearly five months ago, Muhammad has met with community leaders, advocates, residents, and youth in Alameda County to generate support for the new direction of the department.

Key projects include creating a token program where youth can get time off from probation if they, for instance, obtain their high school diploma or raise their grade point average. He wants probation officers located in community service centers across the county so people can get services when they check in with their probation officer.

An advocate of rehabilitation programs that include peer and professional counseling, Muhammad pointed to the Missouri Model, a system that juvenile justice advocates across the country tout as a promising alternative to detention centers, as a model that can work in Alameda County.

The Missouri Model centers are small. The staff is trained in youth development. There’s a strong focus on giving teens job and life skills so they can transition back into society. Teens are held responsible for each other’s behavior. They also undergo deep treatment to understand what caused the delinquency.

“You have to perform well in school. That’s how you can earn your way out of the facility. It’s not just doing the time like most places,” Muhammad said. “Your really have to earn your way out by engaging in treatment and rehabilitation.”

Youth offenders who go through the Missouri Model have a lower recidivism level. Seventy percent of teens released in 1999 didn’t return to any correctional program three years later, compared to a 45-to75 percent of the re-arrested rate country wide, according to a study by the Youth Transition Funders Group, “A Blueprint for Juvenile Justice Reform.”

The probation department oversees two juvenile justice facilities: Juvenile Justice Hall and Camp Sweeney. Youth who sent to Camp Sweeney for become wards of the state, and learn anger management and employment skills. Camp Sweeney in San Leandro trains youth ages 15-to-18, who are wards of the state, in anger management and employment skills. But the county, Mohammad said, should have programs that incentivize good behavior.

Muhammad also plans to implement a progress-tracking system similar to CompStat, called ProbStat. ProbStat would collect and analyze data in each probation division. Muhammad would meet once a month with division managers. “[They would] answer to me,” he said, “if they didn’t meet the measure, or be congratulated by me if they met the measure.”

Alameda County has also implemented alternatives to locking up youth and adults, including GPS monitoring and home supervisions. Some programs aimed at persona growth—yoga and literature courses—are being used for those who are in custody.

And in 2007, the county created a multidisciplinary team including heathcare workers, judges, probation officers and child advocates to direct offenders to existing resources. The Alameda County Juvenile Collaborative Court, for instance, helps youth with mental illnesses get the help they need, including mental health screenings, individual and family counseling, and medication.

Studies have found that a host of social conditions affect a person’s health, including where a person lives, occupation, education, and income level. Youth in the juvenile justice system, Muhammad said, need a range of services to support their health, behavior and education. He wants to partner with community groups to streamline services, and create a place where youth can get, for instance, academic tutoring and visits to their probation officer in the same location.

“It’s a place where it’s their space, instead of going to the offices downtown, where it can be a scary place and they can be waiting forever for their probation officer who may or not be there,” said Jackie Johnson media relations associate for Youth Uprising. Their center and the probation department have partnerships that are working well, Johnson said.

Challenges ahead

The first priority of the chief probation officer, Muhammad told a crowd during the March 17 gathering at YouthUprising in Oakland, is to keep the public safe. Once public safety needs were met, however, the next priority is “to turn people’s lives around,” he said. During that event, the auditorium was filled with youth, juvenile justice advocates, law enforcement and judges. People lined up outside the auditorium for the chance to hear him speak.

“Muhammad comes with a lot of ideas, a lot of energy and it’s unusual, it’s different,” said Lori Jones, director of the Alameda County Social Services Agency. “It’s not what you typically see from a probation chief.”

Muhammad seems like credible leader for this turnaround – he experienced poverty, life in foster care, and the juvenile justice system in his early teens. He credits Omega Boys Club in Oakland with helping him turn his life around. Muhammad also served as Deputy Commissioner of New York City’s Department of Probation before taking the Alameda County position.

Yet youth advocates acknowledge that despite the pledges of support he’s received from community agencies and service providers, he’ll need to get total buy-in on his proposals. Change doesn’t come fast or easy, even when there are a significant number of people rallying behind the projects, they said.

“His biggest challenge will be to get people to see that change is needed,” said Jones of the county’s social service agency. “He comes from the community, which helps him. People will listen to him. Changing perceptions of probation’s role- getting stakeholders to accept a probation department that’s not about “trail, nail and jail” will be Muhammad’s challenge, she said.

Muhammad agreed. “I need the support to be tangible as well. I’m going to need support with the budget, with partnerships to help on various levels.”

Kaina Walker, mentoring program director with Youth Justice Institute, said Muhammad will also need to focus on re-entry.

“One of the challenges that Muhammad will have to deal with is what to do with juveniles who will be returning from the DJJ system. Who will be monitoring them?” Walker said. “In the meantime, these kids are left out without any jobs, without appropriate housing, without appropriate education.”

Adults returning home from jail or prison, or supporting at-risk kids, will also need jobs – a hard problem to solve.

“People who are highly educated are having a hard time getting job opportunities. For a lot of people who are coming back on probation or parole, they have it worse,” Walker said. “It has a trickle effect. It directly affects the kids. If you mom or dad is coming home those are huge tremendous stressors. The kids feel they have to take over to help.”

Reaching out to the community

Muhammad said he wants to ensure residents’ ideas are heard. One way he plans to involve them is through public town halls starting this summer.

The town halls would be held in various parts of the county and stakeholders, including parents, youths, advocates and service providers would get a chance to “not just be at the table, but be fully engaged,” Muhammad said.

He has already created similar meetings with non-managerial staff his department, something he’s calling “listening tours.” The tours work like this: Muhammad meets with line employees who speak candidly on what’s working and not working in their respective offices. The staff shares with him their ideas on how to improve it. Muhammad then meets with managers to talk about how to correct those issues.

“We’ve got deeply entrenched problems. It’s not going to take a week, a month, a year,” he told the crowd.

Thanks to a newly-announced partnership with nonprofit Clinica Sierra Vista, the Kern Medical Center Health Plan will be able to reach isolated areas of the county like Arvin, pictured here. Arvin, which is located 15 miles southeast of Bakersfield is a primarily agricultural community.

By Kellie Schmitt

Terrence Johnson, 24, hasn’t had a primary care doctor in years, despite his nagging asthma.

But after a particularly severe cold wouldn’t go away, he knew he needed help. A friend pointed Johnson to the county-administered Kern Medical Center Health Plan, and he was able to get insurance and see a doctor.

“Now, I have a primary care doctor who is going to find out what’s in my lung,” said Johnson, who works in water maintenance. “It’s a wonderful thing. Now I can go to my primary care doctor in Tehachapi.”

Johnson is one of Kern County’s low-income adults who now have insurance as part of the state’s “bridge to reform” health program. During the first phase, Kern and nine other California counties received federal funding to expand their health coverage for low-income, uninsured residents. That pilot program is now being expanded statewide in an effort to prepare California for the sweeping reforms set to begin in 2014 under federal healthcare reform.

In Kern County, a recently-announced partnership with nonprofit Clinica Sierra Vista would broaden the program’s reach here, expanding coverage to more rural outposts and isolated farming communities. That addition is especially relevant for a county where many residents live in remote, rural regions with scarce access to care. With Clinica on board, the plan’s total medical sites will jump to 26, more than half of which are located outside Bakersfield in places such as Arvin, Lamont and Lake Isabella.

“With us, they have a delivery system in towns where previously they had nothing,” said Steve Schilling, CEO of Clinica, a private organization that provides primary-care services. “We need to start getting these folks into a system of care, to learn about them, and to bring improvements in their health status.”
 
A Bridge to Care
 
The first phase of the KMC Health Plan began in September 2007 as part of Section 1115 of the Social Security Act. Under that provision, select California counties received matching federal funds to expand coverage for their uninsured.

At that time, Kern was one of ten counties in California that began to offer benefits to uninsured individuals ages 19-64 who didn’t qualify for care because they didn’t have children or had too many assets. The program applies to citizens and legal permanent residents for at least five years, who are ineligible for other public programs such as Medi-Cal.

These individuals will be covered with the 2014 reform, but state officials don’t want to wait three years to begin primary and preventative care. While the program will not have enough funding to cover everyone that will eventually be eligible, the goal is to begin creating the necessary networks and enrollment systems.

“The idea is to provide them with a medical home, and to get them into preventative services now so we’ll have a jump start,” said Bobbie Wunsch, a management consultant with Pacific Health Consulting Group. “This program is essential.”

During Kern County’s first phase, the program had more limited funding and less of a geographical reach with some of its rural communities excluded. Still, the program reported many successes, said Jacey Cooper, the senior program manager. During the third year, 6,000 people were eligible to seek care each month.

From year one to three, there was a 41 percent decrease in emergency room costs per enrolled member, and a 36 percent decrease in emergency room visits per member. Instead of heading to the ER for problems such as cellulitis, urinary tract infections and asthma, many patients saw a primary care doctor.

“We’re getting them established with primary care instead of episodic care in the emergency department,” Cooper said “We’re looking at their whole care, instead of the one thing they came to the emergency department for.”

That’s exactly what Hector Martinez, 43, noticed when he joined the program in January. Martinez, who was out of a job and uninsured, now sees a physician’s assistant near his Wasco home. During the visits, he is able to address health maintenance concerns such as cholesterol, instead of his most pressing ailment.

“You name it, they checked it,” he said. “They’re on it. They’ll sit there and listen to you, and they’re concerned about what help you need.”
 
Broadening Reach
 
The second part of the plan, which will run until 2014, will apply to counties throughout California. Along with expanding the program’s funding, geographic reach is broadened. Eligible participants must have a medical home within 30 miles, or a 60-minute commute.

Getting Clinica on board – with its 12 locations around the county – is essential to meeting that geographic goal, Cooper said. Previously, the county worked with National Health Services, which has 11 locations in areas such as Taft, Delano and Tehachapi.

“By bringing on both National and Clinica we can cover the full county instead of half the county,” Cooper said.

The county had approached Clinica during the first effort, but they were unable to come to an agreement on reimbursement rates, Cooper said. The new waiver, which began in November 2010, offers better reimbursement rates.

Clinica CEO Schilling says the better funding was just one aspect. He also wanted all of his clinics to be involved, not just the ones in the isolated rural areas. And, he prefers the stricter conditions of the new waiver, such as the geography requirement.

Currently, uninsured individuals can use Clinica’s services on a sliding scale, but those patients usually came on an inconsistent basis, he said.

“If you’re poor or have a modest income and you’re uncovered, you pay, but maybe you avoid coming next time or you try to stretch out the next visit,” he said. “The ultimate aim and objective is that their health status will improve over time.”

Schilling says that goal will be accomplished with more preventative care and earlier intervention with chronic diseases. That care is especially important in the isolated rural communities Clinica serves, areas where they’re often the only option in town. Too often, doctors coming out of school don’t want to live in these rural locales, he said.

“You have to have an organization, an entity that makes a strong moral commitment to a community and stays the course, regardless of comings and goings,” he said.

While Schilling still describes himself as having “healthy skepticism” about the plan, he said he’s optimistic this round will be better. “I’m more confident, but we’re way early in deciding if this is brilliant.”

Clinica’s contract isn’t finalized yet, but the country says it’s expected to be complete by July.
 
Challenges Ahead
 
The challenges to implementation are “huge,” says Wunsch, the healthcare consultant. For one, the county needs to make sure it’s in compliance with the new federal rules, some of which are still being negotiated, she said.

Strong education and outreach also will be essential since many of the intended participants aren’t familiar with primary and preventative care.

For previously uninsured like Johnson, the Tehachapi resident, that’s a hurdle he’s willing to get over. Johnson says he used to resist going to the hospital for care, but now he feels in control of his health.

“I am happy and grateful that I got the insurance,” he said. “It’s very helpful to have it – you need your health.”

Environmental services worker Israel Olivares marks his ballot as he shares a laugh with Yolanda Zazueta

By Robin Urevich

Hospital cutbacks and lay-offs are on the rise statewide, but at Salinas Valley Memorial Hospital, a cost-cutting plan that could claim as many as 200 jobs and radically reduce health and pension benefits has workers threatening to walk off their jobs in protest.

“Our philosophy is when workers stand together, they can and do prevail,” said Leighton Woodhouse, a National Union of Healthcare Workers spokesman.

The NUHW has struggled to make that case to the state’s healthcare workers ever since it broke from the Service Employees International Union, the nation’s largest labor union, two years ago in a dispute over local control and governance.

During that time, the two unions have competed in representation elections around the state.

So far, just 7,600 employees in hospitals and nursing homes statewide have opted to join NUHW, while more than 140,000 have stayed with the SEIU, according to SEIU spokesman Steve Trossman.

But now, in Salinas, the union has another chance to prove itself, if it can win a solid contract and block lay-offs.

After 28 years of caring for patients at the hospital, Licensed Vocational Nurse George Ross said he could soon be out of work if the lay-offs are approved.

In addition to the job cuts, the hospital has proposed a wage freeze, a shift from a defined benefit pension to one that’s similar to a 401.K, as well as a sharp rise in health insurance co-pays and deductibles.

“Some employees will be in the unique situation of working at the hospital and not being able to afford care at the hospital,” Ross said.

Ross, who serves on the NUHW bargaining team, staffed the polls April 25 as nursing assistants, respiratory therapists, housekeepers, and dietary workers filed into a hospital meeting room to cast ballots in a strike vote.

By day’s end, the union reported a 258 to 58 vote in favor.

Now, as many as 700 SVMH workers who clean rooms, make beds, give medicines and take x-rays could abandon their posts for picket lines in the coming weeks to pressure the hospital to reconsider the cuts.

SVMH, Monterey County’s largest healthcare provider, was already in turmoil before the strike vote. Its CEO of nearly 40 years, Sam Downing, abruptly announced his retirement this month.

Days after the announcement, a handful of caregivers pleaded with the hospital’s five-member elected Board of Directors at a standing-room-only meeting to stop the cutbacks.

“Although I consider myself a very efficient person, I feel inadequate because all the efficiency techniques don’t seem to be working,” said Mercey Stoffey, an oncology nurse. “I don’t have time to give that quality care. Without aides, it’s going to get really bad,” Stoffey said.

The hospital has already shaved some $34 million from its $350 million yearly budget, but administrators say about $15 million more must go, most of it in labor costs. Union members question the need for such deep cuts, pointing to financial statements that show the institution operating in the black.

Fueling the workers’ anger is the hospital’s decision to pay Chicago-based consulting firm, Wellspring-Stockamp, more than $2 million earlier this year for advice on cutting jobs and benefits. Union leaders are also furious over the nearly $4 million supplemental retirement benefit Downing will receive in addition to his $150,000 annual pension. They point to the hospital’s hiring of another corporate consultant, McKinsey and Company, and in a recent Monterey Herald op-ed questioned whether McKinsey is advising the company on privatization.

Not so, said hospital spokeswoman Adrienne Laurent. SVMH is a district hospital governed by a publicly elected board, and privatization would require voter approval.

SVMH has been hurt by a decline in privately insured patients and an increased demand for charity care, said hospital Vice-President Bev Ranzenberger.

While the hospital still runs at a surplus, its bottom line is shrinking, and isn’t sufficient to pay for capital improvements the hospital must make, argued SVMH consultant Mike Profumo.

Meanwhile, Ranzenberger said Med-I-Cal payments have been cut and a major insurer has demanded deep discounts.

“All of that is forcing us to decide what to do to evolve,” Ranzenberger said. “We are going to treat patients in a more efficient manner while maintaining quality.”

If workers strike, Ranzenberger said, “We’re looking at all options. We’re being proactive. I’m confident we’ll meet the needs of our medical staff.”

Ranzenberger said she was equally confident the hospital would make its proposed cutbacks, even as the NUHW wages an all-out battle against them while taking on the SEIU.

The NUHW has asked the National Labor Relations Board to overturn a recent election in which the SEIU won the right to represent 40,000 Kaiser Permanente workers in Northern California, arguing that the SEIU and the employer illegally colluded to thwart the NUHW’s campaign. Later this year, an NLRB judge will decide whether to order a re-run of the vote.

“I think it’s pretty much over,” Trossman said, adding that his union no longer considers the NUHW a threat.

Local NUHW supporters say the union is already a force to be reckoned with, having partially beat back a previous round of job cuts at SVMH last December.

Nina Perez, a bargaining team member and labor and delivery technician, says local workers stick together.

“We deliver babies. We go to quinceañeras. We’re family. We’re going to fight for one another.”

On a recent Tuesday afternoon after hours of negotiations, Perez and a couple of her fellow bargaining team members relaxed over sandwiches at a local Denny’s.

“What’s at stake?” asked Marilyn Benson, an LVN and veteran union activist in her seventies. “Our entire union, our contract, and all of our benefits.” In short, she said, everything she’s fought for in her 38-year career.

“It’s important for me. I’ve always believed in unions. It’s important for me what I leave behind,” Benson said.

patient Baldemar Sanchez is examined for mouth blisters by Dr. Suchitra Rao at the Golden Valley Health Center in Merced. A Spanish translator helped Sanchez communicate with Rao

By Tim Moran

Merced County, like the rest of California, is home to a growing population of ethnic minorities. The county also offers a glimpse into the future, a window onto how healthcare services might need to change to address the needs of a changing community.

The rapidly growing Latino community is not a minority in Merced – it makes up almost 55 percent of the population, according to the latest Census data. The county is also home to thousands of Laotian refugees. More than 45 percent of the Merced County population speaks a language other than English at home.

That poses some unique challenges for the health care providers in the county, from language barriers and cultural obstacles to lack of access for undocumented and uninsured immigrants.

Translators are widely used in clinics and at Mercy Medical Center, Merced’s hospital. The hospital has a full time Hmong interpreter, and Spanish-speaking employees are found throughout the health care system.

But sometimes the language problems go deeper than just interpretation, according to Palee Moua, director of cultural services at Healthy House in Merced. Healthy House provides translation services to area doctors and clinics.

The Laotian, Hmong and Mien language structures are very different than English, and some things don’t translate well, she said. If a doctor allows a child or family member to translate for a patient, potentially dangerous misunderstandings can take place.

Moua gives an example of an elderly Laotian man who came to the doctor with a variety of health issues: diabetes, hypertension, high cholesterol and stomach pain. He brought his son with him to translate. He was given medications for each of his conditions, and told to take them once a day.

His conditions didn’t improve, but the man insisted he was following the doctor’s instructions. Moua was finally called in to try to determine what was happening. She found that he was taking one medication each day, rather than each one each day.

In Southeast Asia, doctors usually treat one problem at a time, she said – perhaps treating diabetes first, and waiting until the patient has that under control before addressing the next condition.

“People feel if they take too many medications, it will kill them,” Moua said.

The cultural barriers are the most severe with the Hmong refugees, and were explored in the 1997 book “The Spirit Catches You and You Fall Down – a Hmong Child, Her American Doctors and the Collision of Two Cultures,” by Anne Fadiman. The book documents the clash of beliefs between the Hmong shaman spiritualism and western scientific medicine through the difficulties of a Hmong family in Merced whose daughter developed epilepsy.

The medical community in Merced has come a long way since then, and there are now training sessions for the shamans, introducing them to the technologies used in Western medicine, so they can reassure patients that western medicine can help them, while the shamans attend to their spiritual needs.

The shamans are trained to recognize emergency situations like heart attacks, strokes and appendicitis, and to get those patients medical care immediately, Moua said.

Transportation is also an obstacle, Moua said, because the hospital, Mercy Medical Center, moved from south Merced, where the poorer Southeast Asian and Hispanic populations are, to a new facility in north Merced.

The older Laotian refugees don’t drive, and their children are working and don’t have time to drive them, Moua said. They are uncomfortable taking public transportation if no one else on the bus speaks their language.

Robert McLaughlin, a spokesman for Mercy Hospital, said the hospital ran a shuttle after the move, but found very few people used it. The hospital maintains a clinic in the south Merced area that is well-used, he said.

Latinos have a different set of problems, stemming mostly from a lack of health insurance. Many Merced County Latinos are undocumented, and so are not covered by MediCal.

Federally-qualified health clinics offer treatment to everyone, on a sliding payment scale depending on the patient’s ability to pay, noted Michael O. Sullivan, chief executive officer of Golden Valley Health Centers, which operates 25 health centers in Merced and Stanislaus counties.

“Undocumented immigrants are a segment many people don’t talk about,” Sullivan said. “No doubt many of them are not here legally. They come here for employment, and they have no access to health care. They can come to this health care system (Golden Valley) and get care.”

The federally qualified clinics get reimbursement for that treatment, but if the patients need specialty treatment, they are frequently out of luck. Specialists are in short supply in Merced County, and without insurance, it’s tough to get treatment, said Tammy Moss Chandler, the county’s director of public health.

“Access to health care is not a human right in this country,” she said.

A big question mark is what happens after 2014, when (and if) the federal health care act takes affect. It does not include undocumented residents, Sullivan said – “And there are a ton of undocumented people here, and they aren’t going away.”

That means millions of Californians still won’t have health coverage, Sullivan said. Hospitals have to treat them in emergency rooms, but it’s unclear who foots the bill for that, he said. “Someone has to take responsibility…Politicians don’t want to recognize that.”

Most private practice doctors don’t accept many uninsured patients – they are running a business, and can’t afford to give away services. Doctors who do see uninsured immigrants are already not getting paid, and then face the cost of providing an interpreter, noted Moss Chandler.

There is a shortage of primary care as well as specialty doctors in the county, Moss Chandler said, which makes access to health care that much more difficult. Many of the doctors in the valley are recruited from foreign countries, and nurse practitioners and physician’s assistants are used to fill in the gaps, Sullivan said.

Many of the language and cultural problems will be resolved with time, Sullivan said. The second and third generations of Mexican and Laotian immigrants will be legal residents, they will speak English and will have integrated into the culture.

But a bigger health care challenge that affects Latino, Southeast Asian and portions of the white population is likely to remain. Almost a quarter of the county’s population lives below the poverty level. Poverty is a driving factor in many health problems such as diabetes, coronary heart disease and strokes.

Merced County ranks near the bottom of California’s 58 counties in those chronic disease categories, Moss Chandler said. The county is worked with Santa Cruz and Monterey counties in the Central California Alliance for Health to get people enrolled in health programs.

The problem is an American one rather than an immigrant one, Sullivan said. Newly arrived Mexican immigrants are relatively healthy – they work hard in the fields and haven’t been exposed to the high calorie, high cholesterol fast food diet.

Simple exercise strategies like walking and bicycling are risky in violence prone poorer areas. The stress of living in that violent atmosphere and dealing with discrimination and isolation is also detrimental to the health of immigrant populations, Moss Chandler said.

Health care providers will have to get beyond the walls of the hospitals and clinics to address those problems, Sullivan said. “That’s where health care needs to go, toward wellness and prevention,” he said.

By Margaret T. Simpson

Maria “Lou” Calanche believes in dreams. But Calanche, a community activist since her teens, knows that residents of the Ramona Gardens housing project need leadership skills to turn their dreams into reality. As Executive Director of the Boyle Heights non-profit Legacy LA, she works with parents and at-risk teens to find alternatives to the gangs, violence and drug addiction that perpetuate the cycle of incarceration, teen pregnancy and low graduation rates.

Headquartered in the former Hazard Park Armory it leases from the City of Los Angeles, Legacy LA offers programs in youth leadership, tutoring and gang intervention. New projects include a young men’s book club, cooking classes for teen girls and a mentoring program.

Legacy LA is in its third year of operation with funding from the Mayor’s Office of Gang Reduction and Youth Development, L.A. Department of Recreation and Parks and private foundations.

Calanche grew up in the Ramona Gardens neighborhood. She is a professor of political science at East Los Angeles College and has been active in community advocacy in Boyle Heights for many years.

In March, 2010, she was named 45th Assembly District Woman of the Year by Assembly Member Kevin de León (D-Los Angeles). She received the Unsung Hero Award from Madres del Este de Los Angeles (MELASI) and is the former chairperson of the LAPD Hollenbeck Community Police Advisory Board.

In this interview, she talks about the challenges and rewards of leading Legacy LA through its next phase of programs.

You’re the first executive director of Legacy LA, but you’ve been involved in the community for many years.

When I was in elementary school there was a leadership program for 4th-6th grades. The kids were able to do something with their lives. I said one day I’m going to come back to my neighborhood and develop a leadership program. When I was 19, I started a program for local girls — a sports program at Hazard Park. It became very successful.

Before I became Executive Director in late 2007, I volunteered at Ramona Gardens. I wanted to empower women. The moms wanted three things: a youth center with more opportunities for kids, better education to improve the low graduation rate and ways to deal with neighborhood tension from gang issues and police. The moms started visiting youth centers to get ideas about what they wanted, and the Legacy idea came up because the Armory became vacant.

You see a connection between family problems and teen behavior with gangs and substance abuse.

That’s a huge issue in this community. A lot of these kids live in single-parent households. A lot of them have their dads and family members in prison. There’s a direct connection with an unstable home and the kids being in trouble.

Once the kids are out of school, after 3:30, there’s nothing for them to do. So then it becomes really easy to get into a gang: mom’s not home, mom’s working, mom’s on drugs. There’s alcohol abuse, or they’re abused. Even the moms who want to be in the lives of their kids feel guilty because there’s no dad, and they don’t want to punish the kids. The issues in the home are directly connected to being high-risk. The big issue is drug use for the teens. Nobody’s watching — it’s really, really easy. That just starts all the problems. Some kids are super resilient, even with very unstable homes, but that’s not the norm

There’s a tendency to want to just put them away. We need to help the young people in our community who are on drugs and in the gangs.

Talk about some of the specific problems you encounter with teens.

By L.A. city law, if you’re a known gang member, the city puts you on an injunction. Gang members have to be served with injunction papers. It limits what you can do. You can’t hang out, and two gang members can’t be seen together. It’s been very punitive. Most of the guys in the neighborhood are on the injunction.

The gang injunction also creates other issues for cops and politicians. Gang members move to other areas and recruit in new areas.

The girls are really in trouble. They’re engaging in behavior worse than the boys — using drugs and inhalants. They want to hang out and get high, and they’re preyed upon by older gang guys. The first step is hanging out, the next step is pregnancy.

It took a while to get older girls to commit, to build that trust and rapport. We have to have incentives. They were just hanging out in the street, in the projects. The older girls are going to start the cooking class; it’s what they wanted. Little by little, it’s changing. We’re planning a hiking trip next weekend.

One of your new projects is a young men’s book discussion group.

We started with the gangs in Ramona Gardens. It was a way to get them together so they can talk about their issues and struggles. They read The Alchemist by Paul Coelho. It has a lot of symbolism; it’s about a journey and making your way, making choices. It resonated with them. They’d take turns reading and discussing how it connects to their lives. It helped to work on their literacy skills.

We just started another book club with the younger, high-school age guys who were getting into trouble, testing the water. These are very at-risk kids, boys already involved with the gang. For them it’s cool because the older guys liked it. Their only role models are the older guys. We’re making reading cool, and it’s working.

Legacy LA was just awarded its second grant from the California Endowment.

The award was funded in January. It’s a two-year youth leadership program for $150,000 each year. The kids will be working on campaigns to develop a healthy community in Ramona Gardens including access to healthy food, the gang injunction issue, improving air quality and decreasing access to alcohol and drugs. We have a youth council with four youth leading each of the four campaigns.

How will your work with at-risk youth improve health care?

While working in Boyle Heights to develop the plan for the Endowment, we talked to residents. One of the target outcomes was to increase access to health care. But it wasn’t something that was a priority because so many young men were in trouble.

The kids who are doing drugs — there’s something that’s missing in their lives. We have to build them up as individuals and strengthen them internally to make better choices. We’re building them up because nobody else does. They have so many obstacles in their homes and their community. Part of it is showing them that we care about them: so you were arrested, now you’re out, what’s the plan? No judgment. Then they can get health care because they care about themselves. They can think about preventive care.

What are some of the unique challenges of Ramona Gardens residents?

I grew up in this neighborhood as well. When I came back to the neighborhood in 2007, I started to work with moms as agents of change. When I was growing up there was still a sense of hope, but these moms had very little hope. They were just happy if their kids graduated from high school and didn’t get into a gang. People became acclimated to the environment. This is Ramona Gardens; this is how we’re supposed to live our lives. They don’t see past it.

People are very dated, very distrustful of outsiders coming in. It’s even been difficult for us, and all my staff grew up here. It’s an intact neighborhood where people don’t necessarily leave. That’s good and bad. For a lot of them, this is all there is; there’s nothing outside of Ramona Gardens. Even if they get evicted from the projects, there’s a residential area outside the projects, and they move there.

But the world is huge. Our job is to show them. It’s labor intensive work.

You believe in dreams as vehicles of change.

If you dream big, big things will happen. If you have small dreams, small things will happen. The mothers wanted more youth programs. The Armory became available, and we organized to bring programs to the Armory. It’s pretty exciting. Because people don’t leave, I see us doing long-term things like the Harlem Children’s Zone. We’re just at the beginning of this. We can start with 2nd grade kids and work with them until they go to college. So the norm is to go to college, not the exception. You can do a long-term investment and track them into college for 12-13 years. So that’s possible. It’s about changing their whole environment.

You have a new mentoring program in the works.

We’re trying to create opportunities for these kids. As we become the mentors, we see the difference we’re making in their lives. Even the book group wasn’t about the books so much as it was about being with adults who cared about them. But there’s a real need for mentoring.

We’re looking for funding and have submitted some proposals for a two-year grant. It takes a lot of work to manage kids. We’re also looking for adults who have gotten out of the drug culture. The more positive mentors they have, the better.

What is your biggest challenge for the future of Legacy LA?

I have to build the infrastructure and develop the capacity of the people who live here to run it. I’ve been that person people turn to, but I need to think about how in 8-10 years this can still exist without me by building leadership and capacity.

If we can build a successful program, we can build impact. It’s not just for Ramona Gardens, but for the surrounding area. I’m happy to say that we’re going on our third year. It’s incredible to be able to get funding for a start-up organization like this.

My goal is to develop a program to last for a very long time.

Reagan Elementary student Morgan Polley identifies a right angle with an interactive whiteboard. Going paperless and using more technology are cited by principal Robb Christopherson as ways to reduce costs and teach more effectively.

By Derek Walter

Larger class sizes. Salary cuts. Furlough days. Layoffs.

These are the grim choices facing school board members throughout California after another year of crushing budget deficits. Yet more tough choices remain.

Gov. Jerry Brown was unable to convince enough Republican legislators to place a ballot initiative before voters that would extend temporary tax hikes set to expire in June. While there is now talk of placing a ballot measure before voters later in the year, California might still be forced in the interim to make an additional $5 billion in cuts to schools, according to the state Legislative Analyst’s Office.

The cuts will result painful decisions for school districts in the San Joaquin Valley, an area that already services many of the state’s poorest families. For example, Fresno Unified School District must slash another $70.9 million from next year’s spending plan, according to Budget Director Santino Danisi. As if this wasn’t bad enough, these cuts come on top of $88 million already scratched from this year’s budget.

Class sizes in kindergarten through third grade, which grew last year from 20 to 24, will expand again to 30 students per class, according to Danisi. He also said salaries could be cut for all employees by five percent. These reductions and other cutbacks invited criticism and concern from district parents, many of who have lashed out at board meetings.

“It is just so disappointing, all they talk about is cuts,” Fresno Unified parent Angela Gonzales said when asked about morale among parents.

“Undoubtedly there are community members that are pretty upset and they have been turning out to express their discontentment,” Danisi said. “But many are understanding of our situation. We get our revenue from the state and we must do what we can to bridge the gap.”

Clovis Unified, the second-largest district in Fresno County, is also beset with problems caused by the budget crunch. All employees took salary reductions during this school year and will do so again next year. A number of administrators are being reassigned back to teaching positions in the classroom. Yet even with these reductions an additional $12 million in cuts must be implemented now that the tax negotiations are dead, according to district spokesperson Kelly Avants.

“I want our community to understand that we are in a grave situation, and that what happens in Sacramento in the next few months is going to have a significant impact on Clovis Unified, our students, our employees, and ultimately our future,” said Clovis Unified Superintendent David Cash in a letter to community members.

While administrators in the district office grapple with the numbers, teachers and principals try to focus on their daily jobs, despite looming uncertainty. The anxiety is primarily from STAR testing, the state’s high-stakes accountability program. Students’ performance on the various subjects of the California Standards Test (CST) determines a school’s Academic Performance Index (API) rating.

Robb Christopherson, the principal at Reagan Elementary School in southeast Clovis, said the largest struggle for teachers is dealing with the unknown.

“The biggest thing we are dealing with right now is uncertainty; we are planning for the worst and hoping for the best,” he said. “Unfortunately, we are at the mercy of the state and the budget process.”

At the same time he said there was room for optimism. For example, he said using more technology tools was a way to do more with less.

“Educators are creative beings and when times change, our creative juices begin to flow even more. As long as we are all willing to hold on to our core values and continue to focus on student achievement for all students, we will easily weather this storm and, in fact, will probably be more efficient and effective at doing what we do,” he said.

For example, Reagan and nearby Freedom Elementary both no longer send out paper copies of their weekly calendars. Instead they are posted on the schools’ web sites. Also, many teachers at Reagan update parents through classroom web pages and online gradebooks, which further saves on printing costs.

Christopherson also cited the use of interactive whiteboards and deeper integration with technology throughout the school day as ways to further engage students even while their school has less money for resources.

There is still a slim chance that the worst-case scenarios that schools are preparing for may not come to be. Gov. Brown indicated recently that he will appeal directly to voters and push for an initiative to extend the temporary taxes on the November ballot. While doing so would not end the current need for deeper cuts, it could give districts some relief later in the year.

Budget Director Danisi and others will also be awaiting the California Department of Finance’s revised budget proposal in May. If the plan for closing the budget gap is solely through cuts, then those worst-case scenarios like five-percent salary cuts and increased class sizes will come to fruition.

Budget Director Danisi, Principal Christopherson and others will need to check the news often, as proposals and offers between Gov. Brown and legislators change with great regularity. Either way, it will likely be another year of trying to meet the state’s expectations with even fewer resources.

Derek Walter is a fifth grade teacher in the Clovis Unified School District in Fresno.