It's a typical Thursday afternoon at Mercy Family Medical Clinic in Merced. The waiting room is full. Regular patients mingle with the 30 or so people who have waited weeks to get into a special weekly dermatology clinic.
They've got only a four-hour window to be seen by a skin specialist, Dr. Albert Col. The doctor and two residents must diagnose eight patients an hour. Patient ailments range from eczema to skin cancer.
Col runs a private practice in Merced, but spends most of his time treating patients at similar specialty clinics in Atwater, Mariposa and other rural sites.
At Mercy, Col keeps color photos of some of the most serious cases posted on his office door to show the medical residents training there. One patient walked in with a mummified cancerous growth sticking out of the top of his skull. Another made it as far as the clinic with a cancerous gash the size of his ear on the back of his head.
Dr. Col, this clinic and others in the Valley see the worst of the worst. Many of their patients have gone without necessary care for years. The patients have never been exposed to care that might prevent the worst from happening to them.
Mercy Family Medical Clinic is a "safety-net provider" in Merced -- a nonprofit clinic that cares mainly for the poor and uninsured. Similar one-day specialty physician visits are a way of life for many residents, who know they need to book appointments weeks in advance. The staff is well aware of how desperate residents are for care. On a recent Thursday, a woman showed up more than an hour late for her 2 p.m. appointment. She told the nurse she had car trouble. To spare her several weeks' wait, the nurse decided to squeeze her in that day.
Some specialty clinics set appointments even less often. Right across the street, for example, patients crowd into a waiting room for a pulmonary clinic held once a month. On other days, specialty clinics are set up to treat podiatry or fracture injuries. Almost like circuit-riding judges during California's Gold Rush days, doctors move from hot spot to hot spot, in effect applying a Band-Aid to a sucking chest wound.
Lack of access to care affects people of all walks of life here. Out of the 58 counties in California, Merced ranks 55th for its high diabetes death rate, yet there is only one endocrinologist in the entire county. The number of senior citizens receiving flu shots in Merced -- 58 percent -- is among the lowest in the state.
San Joaquin Valley residents have the least access to physicians per capita of any region in California. On average, there are 302 physicians per 100,000 people in California. In the San Joaquin Valley, the number of physicians plunges to 173.
In many communities, there is no dermatologist, psychiatrist or cardiac surgeon. As a result, residents hobble through life without pertinent care or travel huge distances for it. Cardiologist Dr. Hanimireddy Lakireddy has practiced in Merced for 24 years. When he hung up his shingle in town more than two decades ago, there was no heart specialist. He was the first, Lakireddy said.
Over the years his job has swung from fairly easy to just plain frustrating. As recently as just a few years ago, Lakireddy said he could refer his patients to any one of four cardiac surgeons in town.
Today there are none.
"It is really sad. We really need more doctors, more specialists," Lakireddy said. "Instead of getting better, we really are going the other way."
The Valley is home to a number of persistent social and environmental issues that worsen medical problems.
People are poor in these parts. One in five people in the San Joaquin Valley live below the federal poverty line, according to UCLA's California Health Interview Survey.
In six of the eight counties that make up the Valley's geography, more than one in four children live in poverty, according to the Great Valley Center, a nonprofit organization partnered with UC Merced to improve the overall well-being of the region.
Educationally, San Joaquin Valley children are less likely to be enrolled in preschool, to take classes required for admission to the UC or CSU systems and to take college entrance exams.
More than one in five students in California drop out of high school. Five of eight counties in the San Joaquin Valley post an even higher rate.
Transportation is hard for poorer families, particularly in a Valley so big that trips are often measured by hours, not miles. It is one of the many issues that affect access to care, but one that can't be solved by an increase in doctors and residents.
Christine Muchow, executive director of the Merced-Mariposa County Medical Society, said transportation is the key barrier to care for many Valley residents. "If you need to be seen by a specialist, and we don't have that specialist, they may not be seen at all because they can't get transportation out of the county," she said.
Take 14-month-old Adrian Hernandez, for example.
Adrian is a quiet little boy, with short brown hair and winsome almond eyes. He is the mirror image of his twin brother, Andres -- even their teeth are growing in the same way.
But Adrian has lived a much tougher life.
He's just over a year old and has already endured four major surgeries -- three of them to repair a congenital heart problem, the fourth to treat a club foot.
Complicating his health issues is his family's lack of access to proper care.
There is only one pediatric cardiologist in all of Stanislaus and Merced counties. There is no cardiac surgeon in Merced County at all.
As a result, Adrian is routinely shipped around the San Joaquin Valley just to find care.
His mother, 29-year-old Rosario Cisneros, sighs at the medical merry-go-round of getting Adrian treated. Her son always receives care, but it doesn't come easy.
Rosario can't drive, and her husband takes their only car to work in the fields each morning. If Adrian experiences a medical problem during the day, she calls a friend to get him to the Turlock hospital 40 minutes away.
The trip doesn't end there. Doctors in Turlock call a specialist from Children's Hospital in Madera, who sends an ambulance for him so he can be transported for the care he needs there, Rosario said.
Madera is 70 miles and a 90-minute drive from the family home, but it might as well be in Canada.
Adrian's odyssey is not unique.
For regularly scheduled appointments, the family utilizes a free service dedicated to transporting area residents to medical visits called "Going Places." Since it was created in January 2001, the service has driven hundreds of patients to and from appointments as far away as Los Angeles.
Going Places partners with Healthy House, an area nonprofit organization, to provide health care interpreters for parents like Rosario who don't speak English. (A Healthy House interpreter, Teresa Reagan, translated Rosario's comments above.)
The fact that Adrian receives world-class care at Children's Hospital for his condition doesn't lessen the transportation stress. "There are days when I feel like I am not going to make it," Rosario said. "And then I tell myself 'I don't have a choice. I have to make it.'"
And while Adrian's disease -- transposition of the great arteries -- is rare, many children in the area are beset by regular illnesses borne of their economic or social circumstances.
The 1.2 million children in the San Joaquin Valley are, on average, far sicker than their peers across California. Flanked by the majestic Sierra Nevada on the east and rolling golden hills to the west, the Valley resembles in some desperate ways a Third World country.
One in five children have been diagnosed with asthma, though many more undiagnosed cases are surely lurking in the Valley's forgotten nooks, advocates say.
Leslie Schleth is the lead district nurse for the Merced City School District. Over the past 13 years in her job, she has seen an increase in asthma problems.
The Valley suffers from poor air quality that can cause or worsen health problems, said Seyed Sadredin, executive director of the San Joaquin Valley Unified Air Pollution Control District, which regulates air quality.
Due to a conspiring of topography and meteorology, the bad air is trapped by the surrounding mountains and held down by an atmospheric condition called an inversion.
"We're a bowl with a lid on it," Sadredin said. "The pollution we have doesn't escape." That means that although Los Angeles has 10 times the amount of air pollution per square mile as the San Joaquin Valley, the Valley's air quality is only marginally better, he said.
Studies have shown that pollution exacerbates asthma, Sadredin said. But tiny particles in pollution can cause other ailments, including reduced lung capacity and heart problems.
As a result, the Merced City School District recently began flying air quality flags in front of their school buildings to alert asthma sufferers when their triggers might be increased.
Schleth said that asthma, while an intermittent impairment, resounds with a heavy trickle-down effect on the lives of severe sufferers. When any student must take his inhaler for a second time in four hours, as frequently occurs on days with poor air quality, a parent has to visit the school to administer inhaler treatments, or the student must go home.
"If kids aren't in their seats, if they are missing a significant number of days at school for something like this, they aren't going to be able to learn or function," she said.
Sadredin said he would welcome a new medical school in the Valley, especially if it generated research on any local connections between bad air and illness. Today, most such research is conducted in Los Angeles or in cities on the East Coast.
"I'm thinking that if we have more Valley-specific studies in the region rather than research done elsewhere," he said, "we might get better answers to the real causes of air pollution in the Valley."
And while the introduction of a medical school at UC Merced won't immediately solve the transportation, social and economic issues that plague the Valley's patients, the school's research over time may provide insight, understanding and viable solutions to dealing with those social issues, Vice Provost for Health Sciences Maria Pallavicini said.
A major share of research at the medical school will concentrate on global health, a relatively new approach to medicine that examines health trends among a group of individuals and works to improve outcomes for that entire group.
For the entire group in the San Joaquin Valley, research opportunities seem to stretch forever.
"There are no boundaries for the health problems in our region," Pallavicini said.
Reporters Deborah Schoch and Danielle Gaines can be reached at firstname.lastname@example.org.