FIREBAUGH, Calif. — On a morning in early January, the air is cold and Firebaugh's main street is nearly empty. But the Sablan Medical Clinic is quickly filling up with people eager to see the physicians they affectionately call Dr. Marcia and Dr. Oscar.
Lela Burkhart, whose family owns a farm in this remote San Joaquin Valley town surrounded by fields of pistachios and almonds, is one of the first patients of the day.
Burkhart, 86, recently had heart surgery, and this morning she's feeling tired and short of breath. Oscar Sablan tells her that the lab tests show she is dangerously anemic.
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"You are bleeding inside, even though you cannot see it," he tells her.
"Do I need to go to the hospital?" she asks.
Sablan nods. "It's a little too low for us to wait," he says, patting her on the back.
Thirty years ago, Oscar and his wife, Marcia, made a plan: work in a rural area for three years and walk away without any medical school debt. So they moved from tropical Hawaii to dusty Firebaugh and started a practice in a trailer on the corner of O and 9th streets. They didn't intend to stay.
They are still here, the only full-time doctors in town, treating many of the same families as when they arrived. The couple raised four children in Firebaugh and grew so committed to the town that she served as mayor and he as school board president.
"This became our home," Oscar Sablan says. "I still can't believe it."
After her consultations with the doctor she's known for decades, Burkhart says she will head to the hospital.
She is painfully aware of how far away it is. Twenty years ago, her 42-year-old son believed he was having an asthma attack. Oscar Sablan recognized his symptoms as a heart attack and had him airlifted to a hospital in Madera. But his heart stopped on the way. Sablan says he believes that if they had lived closer to a trauma center, he might have survived.
Sablan promises to check on her once she is admitted. Then he starts making calls to Fresno, nearly 45 miles away. First, the heart doctor. Then a gastroenterologist. Then the emergency room doctor. Each time, he explains his patient's health situation and advises them that she is on her way in.
"I feel uncomfortable treating her as an outpatient," Sablan says to the emergency room doctor. "I'm not that brave … even out here in the country."
Burkhart says the whole town, from wealthy ranchers to migrant farmworkers, relies on the Sablans.
"They've taken care of all our families," she says. "I don't know what we'd do without them here."
But now Oscar is 61 and Maria is 65, and they realize they can't do this forever. They're beginning to plan their retirement, looking forward to giving up their 65-hour workweek and spending more time traveling and visiting with their eight grandchildren. But they're worried about what will happen to their patients.
"These are people we have guided through bypass surgeries, pneumonias, accidents and injuries, cancers," he says. "But it is something we are going to have to do, now or later."
Much of inland California is made up of towns just like Firebaugh, where large swaths of the population are uninsured, where traveling to a hospital means a long drive, and where doctors and pharmacists are in short supply. The nearest hospital to Firebaugh is 20 miles away, and the closest trauma center is nearly 40.
The federal health reform law is designed to help improve healthcare in rural areas by expanding access to coverage and investing in primary care doctors and rural hospitals. But that is an uphill battle in places like the San Joaquin Valley, says Marlene Bengiamin, research director at the Central Valley Health Policy Institute.
In a recent study, the institute found that the valley failed to meet any of 10 national standards in such areas as reducing smoking, reducing the number of deaths from car crashes and improving access to healthcare.
"We fail miserably," she says. "There are so many health challenges in the valley."
The Sablans know those challenges better than most. They've treated gunshot wounds, set broken bones and resuscitated heart attack victims. They've also cared for farmworkers exposed to pesticides and injured in agricultural accidents.
The clinic, now in a single-story white building with a blue awning, sits next to a community college and across the street from a discount store. In the bright, airy waiting room, a television airs a consistent stream of health messages. A few patients read newspapers in Spanish, and children play in a gigantic pastel playhouse.
Jasmin Barrera has brought her 17-month-old daughter, Kayleen Rodriguez, in for an exam. Kayleen was born premature and has severe asthma. In the last few days, she's been coughing more than normal.
"Let's get her up here and take a look at her," Marcia Sablan says, carefully unzipping the girl's pink jacket and holding the stethoscope to her chest. The girl whimpers and wheezes, and grabs at the stethoscope.