Sandra C Clark

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The interview is part of an investigation on the complex interplay between Latino immigrant access to Orange County, N.C.'s healthcare services and their use of traditional medicine. It was organized around a few major themes: Latino immigrant access to formal healthcare services, the role of community health centers in increasing access, and the importance of physicians gaining cultural competent while working with Latinos. As a physician, Dr. Sandra Clark sheds light on the struggles faced by Latinos to access affordable and adequate healthcare services. Her experience working with Latinos at the Carrboro Community Health Center in North Carolina as well as in Guanajuato, Mexico provide an excellent perspective on local and international efforts to improve access to better quality healthcare. Dr. Clark stresses that truly understanding Latino patients goes far beyond just speaking Spanish, requiring an understanding of how they conceptualize health and healing. She attributes her own



Rachel Burns: Hello. This is Rachel Burns interviewing Dr. Sandra Clark on April 5, 2012. We are in Hanes Art Center at the University of North Carolina at Chapel Hill. It is 1:00 pm. Thank you so much for meeting with me. And first, could you maybe starting off telling me about yourself.
Dr. Sandra Clark: So, my name is Sandra Clark. I'm a native North Carolinian, grew up in Charlotte and did my undergrad here at UNC. I was a Spanish and Chemistry major and then went to medical school here and did my residency in family medicine here as well. So, I am married. I have two kids. One of them is an undergraduate here at UNC. The other is in high school. For about 15 years, I worked at the Carrboro Community Health Center as a family doctor with a largely Latina and minority population. I am currently in the School of Public Health boning up on my research skills, so that I can continue to do work and maybe move into more of an academic field once I finish.
RB: Nice, so, you worked at the Carrboro Community Health Clinic for 15 years and could you kind of give me a brief history of what the clinic does and its history?
SC: So, community health centers have been around since 1970s. They get some federal funding and then a lot of their funding comes from the Medicaid, Medicare patients that they see and grants that they receive for the care that they give. And so, patients, theoretically it is for anybody who cannot afford health care otherwise. It's for the people who kind of fall through the usual safe net of insurance. Mostly, minority populations go to community health centers. At least at our community health centers, we have a full pharmacy. We have dental services. We have WIC services. We provided prenatal care, adult care, pediatric care, geriatric care. We had case managers, social workers and whatnot to help us. It's fairly kind of ideal way to service minority health populations.
RB: So, most of the funding does come from the federal government?
SC: Not anymore. When they started, more of the funding, more of the percentage, of the clinic was paid for by federal. Now it is a much smaller slice, like maybe 20-30%. And then, you know another, I don't know, I couldn't even tell you what percentage comes from the Medicaid and Medicare and private insurance, privately insured patients that come in. Because some patients actually do have insurance, they will be uninsured and they'll start their care, and then they will get insurance and they'll continue their care. Some Latinas, even undocumented Latinas, have health insurance through their work. And then the rest of it is paid by, like I said, grants and then you know patients do pay on a sliding scale if they do not have insurance. About almost, well probably more than 50% of patients at the Carrboro Community Health Center are uninsured. So, they will pay, depending, they bring in evidence of what they are making, or not making, and they use that to help set up a sliding scale fee for them.
RB: Wow, and it seems like you all have a lot of services, but what kind of specifically do you work on while you ever there?
SC: Well, I'm a family doctor, so I got to do everything. Really, for me, it was ideal because I love doing prenatal care and I love working with families. So, I get to do prenatal care, then follow the babies once they were born. And then, I do a lot of chronic disease management and then I had a nice little set of geriatric patients. So I did, you know, from other than deliveries, which we do not do, UNC obstetricians do delivers for our babies, but other than deliveries, we pretty much do full spectrum care. Since I am a family doctor, I was able to do a little bit of everything, which is great.
RB: That's neat, so in the past, and over the 15 years you were working there, did a large increase in the Latino demographic while you were there just at the clinic?
SC: Oh, absolutely. I mean Latinos really started coming here in large numbers probably between 15 and 20 years ago. And so, when I was hired by Piedmont health services, the umbrella organization that has all of the community health centers in the area, I was hired especially because I speak Spanish. So, so yeah, I was brought in just as the Latina explosions began taking place.
RB: And, did you have a lot, did your numbers at the clinic kind of rise because of that as well?
SC: Yeah, although my percentage really hasn't because what happened was because I was one of the few persons/physicians that did speak Spanish, always more Latino patients were funneled my way, but certainly by the end when I finished last year, 80% of my patients were Latina. But, you know, that kind of happens. Latinas know who speaks Spanish that is where they will preferentially go. So my percentages have been high. The clinic percentages, of course, have been gradually increasing, increasing, increasing. So, yeah.
RB: And has the clinic been able to manage these increasing numbers?
SC: No, they have not. You know all of the providers, the physicians and mid-levels, nurse practitioners and physician assistants, they were three of us who speak Spanish really well and three or four of us who not quite so well, but have kind of picked up the skills out of absolute necessity. And then, there were, at least in the last couple of years that I was at the Community Health Center, there were so many uninsured, mostly Latina patients, that they actually had to stop taking new, uninsured patients at the clinic because they just couldn't keep up with the demand and the community health centers were actually starting to lose money. So, it's hard. When you had such a huge, uninsured minority demographic, it is hard to give them the care that they need and the care that they deserve, in my opinion.
RB: So, for don't get care or aren't able to receive care at the clinic, where else do a lot of your patients receive their care from?
SC: That's the horrible thing. You know if you tell a patient no, we don't have or you're not Orange County or you know you have not been to our clinic before and we are not taking any more new patients. They go to the emergency room or they go to free clinics like the SHAC clinic. But even then, the SHAC clinic can only see, they are really limited in the number of patients that they can see. There really aren't. There are a couple free clinics in this area. SHAC clinic is one of them and the other one is at the homeless shelter but they typically only see patients that are living in the homeless shelters. Are there any other free clinics? I don't think there are any other free clinics in this area. So they will go to the emergency room, maybe, maybe they can get into one of the other community health centers that Piedmont health services runs. Depending on the percentages, different clinics will accept new patients with specific demographics. The other community health center that is not part of Piedmont Health is in Durham. That is the Lincoln Community Health Center, so some of them will go there. There is also a local physician, Glen Withrow who speaks Spanish. He did Peace Corps in Peru. He is with a place outfit called the Family Doctor. That is his practice. He'll take them but they pay a lot more. They'll pay probably private clinic prices to go there at least they speak Spanish.
RB: Wow. Do you think a lot of the kind of problems stem from just language to not having difficult finding?
SC: Well, language and culture. Language and culture. You can speak the language, but if you're not culturally competent and if you don't really know. And this is something that certainly even when I started out 15 years ago, I spoke Spanish reasonably well, but did I really understand Mexican culture? No. It took actually traveling to Mexico and working with Latina patients for years to really kind of get what was going on and how I could really make a difference in their lives. So yeah, you have to learn, you have to become culturally competent in addition to speaking the language to really do a good job serving Latinos. They have both those needs. Then of course, there is transportation; there's money. There are a lot of barriers for them getting good care.
RB: So would you speak a little bit about your research you have done in Mexico in the past couple of years?
SC: So, several, about ten years ago, there was, at the St. Thomas Moore Church, one of the Latino parishioners said look we have, there are hundred of families from my little town, Juventino Rosas in Guanajuato, Mexico. The church there really wants to establish a sister parish. So, somebody knew that I did Latina medicine, so they put me on the group that initially went down to Juventino Rosas. So about ten years ago, we went down and had our first kind of look at this area. Then a couple years later, we went back and I kind of led a little health fair that we actually did with the Latino physicians down there. We did it all together; we did a health fair. Then they said, why don't we start; this really fun, we like this partnership. Why don't you start bringing more people down? So I actually went to the medical school because there is a program within the medical school called CAMPOS and it is for medical students who are particularly, specifically interested in doing Latino health. I don't know how many students they take into this program every year, but they divide the students up for the summer and they send them all out. They have programs in Honduras and Nicaragua. Do they go anywhere else? I think Honduras and Nicaragua are the main places. So, I went and I said look most of the Latinos in this area are from Mexico. A lot of them are from Guanajuato, Mexico. We have this little town and I have been going down there. I got one medical student very interested in helping and he recruited other and then we started this Projecto Puentes. We started going down probably seven years ago. There was a cardiologist, a UNC cardiologist, who was involved from the beginning as well. We started out by doing little health fairs in the small rural communities outside of Juventino Rosas where the poverty is just incredible. We go down and check blood pressure, blood sugars, cholesterols, and whatnot. Its kind of spread since then. We have got people from public health, people from sociology, people from social work to go down there. Our most recent big project is called MESA. We noticed a lot of women down there who were disconnected from everything. Their husbands have immigrated up here and we were seeing these small towns with essentially no men at all, except for maybe some elderly men and some alcoholic men who really just couldn't or weren't capable of going to the United States. The depression level was just sky-high, so the last couple of years we have started support groups in those rural communities to help those women cope with the family break down that is going down because of immigration to the United States. Now we have extended the relationship. We go to San Miguel de Allendes, also in Guanajuato, Mexico. We have started doing pretty much the same thing there. It's been fun.
RB: Wow, neat. So, with this research that you all are doing and the work you're doing in Mexico, how does that kind or do you think it will ever translate to the Latinos here. With maybe MESA, with the women, I don't know if there is a rate of depression here with just immigrants.
SC: Absolutely. The MESA protocol that I have I stole with permission. Duke and UNC are doing their own similar project called ALMA. That is how I actually started my project MESA. They are doing the same thing. They train Latina, local Latina, women to start their own support groups in their communities with the goal of alleviating stress and depression. So, they actually, I found out they were doing this and I actually asked them for their protocol for their curriculum and kind of translated it and made it more better for Mexico and then took it down there a couple summer ago. But there is also, in terms of mental health, one way that actually got piloted at the Carrboro Community Health Center is now El Futuro. There now is an outfit here. I think the base is in Carrboro, but they also have offices in Siler City and in Durham. El Futuro was started by some psychiatrists who were coming out to Carrboro Community Health Center for a couple of years when they were residents. There is such a need for mental health services for Latinas that they were able to get incredible grants to keep their outfit running. They run it the same way as a sliding scale fee. I think it is probably on the same rate that the community center uses. They have a lot of psychiatrists, psychologists, social workers, working. They do a lot of group therapy as well. It is a nice resource for mental health.
RB: Wow. Seems like there are a lot of resources, or some resources in this area, but I know a lot of it is spread through word of mouth, but do you think it is because we are or maybe you go outside of Chapel Hill, are there a lot less resources for Latinos, maybe in Pittsboro or other smaller towns? What is being done to help spread the word of what you all are doing here?
SC: Well, you know, a lot of community health centers operate in some of the more rural areas. Like we have, when I started at Piedmont Health, I worked out in Moncure, which is kind of way out. It is in Chatham County. We've got clinics in Prospect Hill, two clinics in Alamance County, and for a while we actually had a midwife relationship. They went solo and on their own. So, the community health centers tend to operate in rural areas. The mental health resources, no. El Futuro is fairly unique. For mental health services, there really aren't great. But you know the local health parts in the areas have tired very hard to meet the demand for Latina health needs. Between health departments and community health centers, there is kind of a patchwork of places outside of Chapel Hill and Carrboro that do Latina health, but it is spotty. You need someone, like I said, to really do good Latino health, you need someone who not only speaks a reasonably good amount of language but will charge enough that Latinos can actually go and actually be competent in the culture and what the needs are and understand how they do health care. It is very different.
RB: So based off kind of having that cultural competence and understanding the differences in the health systems, I know that I'm sure a lot of Mexicans or Latinos used to use or still use natural or traditional medicine. How often did that come up in your work or if at all while you ever working at the health clinic?
SC: Well, it depends. Latinas typically, and this is with mental health as well, always try and find a solution in the home, whether it be a mental health problem or a cold or whatever. They will use an herbal treatment. They love teas. Certainly, they use traditional. They will go to the tiendas and actually get amoxicillin. They will get some antibiotics that kind of come illegally through Mexico. They do have a tradition trying other things first. If those, when those fail, that's when they'll start accessing. That is not always. If a child is really, really sick, then they are going to go right to the doctor. They use health care when it is necessary. For light colds or things that they really don't have the money to pay or don't have the access to come, they will always try some type of alternative thing first, either it be from a tienda or an herbal treatment. I haven't seen many curanderos around here. That is not something that is really used that much here. But yeah, they will traditionally try something in the home and if that doesn't work, they will access the formal medical care system.
RB: Most of these you can purchase at the tienda or do they get it from family or mainly from within North Carolina?
SC: Well, some, the teas and stuff I'm sure. Well, most of it they will get at the tiendas. The tiendas are very well set up to give them what they need.
RB: Was there ever kind of ever, based on this problem for access for a lot of the immigrants coming in, is there ever, I guess if something is worst off, they just automatically know to go to the emergency center? Do some show up at the clinic when it was really kind of worse?
SC: [laughs] We had a guy, who he was working on construction and he had a nail in his leg. Okay, you know he wanted to. You know that is expensive to send somebody to the emergency room. So, I showed up at the clinic and he is sitting there was a nail in his leg with a big huge 5 inch nail, nailed into his leg. He is sitting on the bench outside of the clinic and I'm like there is nothing we can do for you. We cannot do this. [laughs] We immediately gave him some morphine and sent him to the emergency room where he was actually not even hospitalized. They took it out and I guess they watched him for infection and they sent him out. There are times that you know once you, it's easy to use the emergency room because you can go. You don't need an appointment, but Latinos learn very quickly that it is so expensive. UNC will work. There are programs that you have to apply for to get reduced, to pay less. You get a couple of emergency room bills and you're just busted. I mean you are paying for years, years, years. They work out payment plans. Latinos initially just used the emergency room a lot and now they will do anything to avoid the waits, the money, the way they are treated. Maybe they will get someone who speaks Spanish; maybe they will deal with a translator. It all gets very complicated, so it they can find a cheaper, more culturally competent resource they will use it.
RB: Do you think there is enough being done in the area or what other projects or what could be done to improve access for Latinos, especially those without insurance?
SC: Well, everything, a lot depends on the new health care performance coming in. Latinos are lucked out because if you're undocumented, you cannot apply for insurance, even they you would be paying for the insurance. That is all a political thing because the best thing would be for everybody to have insurance and be able to pay into to get the insurance. Latinos want insurance, but they are left out of that, but since more non-Latinos, well some Latinos here are documented and have papers and will be able to get the insurance. Since more people will be insured, there might be more money to help to take care of the uninsured, which is largely going to be undocumented Latinos here and other undocumented minorities here. So, a lot depends on health care reform. The future it is especially in areas in North Carolina where you are just seeing this saturation. When the community health centers are breaking down and we can't take care of Latinos anymore, I mean that is just a real problem. We need another community health center here in Carrboro that will take newly uninsured patients. Access is always going to be a problem because those resources fill up so soon. But health care reform should ease the burden on community health centers some. Cause they will have more insured patients, which will give us a better way to take of our we will have more money to take care of our uninsured patients.
RB: Kind of going again back to the issue of being culturally competent, has there been training available for practitioners or people in the medical health careers here to help become more culturally competent?
SC: Well, it is kind of interesting. You would think at the community health center we would actually be almost forced or obligated to do cultural competence training, but we never did. You just kind of learn by, I mean, I learned cultural competence by really misreading, misunderstanding, not getting it. ( ) Actually going to Mexico was like a revelation. You know after my first visit to Mexico, all I had to do was say to any pregnant Latino woman, “how are you going to teach your child? Are you alone? Do you have any social support?” They would inevitably start crying because being disconnected from their family. Being in Mexico makes you realize just how interconnected, social Latinos are. How awful it is for them when they get here. A lot of them will maintain community, will join very rich communities that forming here but some don't. Sometimes it is the men who put them in apartments kind of away from other Latinas intentionally as a control issue. These women who are here they were with this family all day long, going back in forth between family members, and now they are in the United States in an apartment, they don't leave. They are scared to leave. It can be so isolating and so awful and especially if they start having kids. They are just I mean what a horrible thing for them. It took going to Mexico. It takes years and years of just working with Latinas and trying to kind of figure out how they usual go about solving problems, especially health problems. It just takes a long time to get used to that and to learn about how to best treat them.
RB: In for the research your dong in Mexico, have any other practitioners from the clinic gone down as well or are you just?
SC: Yeah, yeah, yeah. We have had, let's see, how many physicians from Piedmont Health have gone down? At least five or six have. I go every year just because I kind of spear headed the whole time. Several physicians from UNC who are not with Piedmont health services go down there as well every year. So it is nice.
RB: How long are you all there for and do you ever give health care services or it is predominately research?
SC: Oh, no, no. So we still, from the beginning we have done health fairs down there. Like I said for the first year we went out, we usually go to the priest down there who usually helps to select communities that really are in need and then we go out and do these little health fairs. Usually during the day, they will do the health fair and check for blood pressure, sugar and when we have the money we will do cholesterol checks as well with these little portable things. Then, we take the afternoon off and then the students go back in the evening and do health talks. So they will talk about, they will just pick an issue: cardiovascular health, women's health. They will just give a talk about that health topic in the evening.
RB: Nice. Do you hope to eventually work again at Carrboro Community Center? Where do you see your path going?
SC: Well, I don't know. What I see is a mix of a little bit of research, a little but of teaching, a little bit of clinical. In so, however, I don't how I am going to find that mix, but that'll be my goal in the next years, where I can find a situation where I can do all three.
RB: Okay, well thank you so much for answering all of the questions.