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In 2016, a pediatrician at a health center facility in Douglas, Arizona, saw a mysterious illness in a young patient.
It was Rocky Mountain spotted fever, a tick-borne disease that can be cured with an antibiotic. But the disease – extremely uncommon in the United States – wasn’t even on the pediatrician’s radar. They missed the diagnosis, and the child ended up in an intensive care unit.
However, just blocks away – but over the border, in Mexico – a town called Agua Prieta was experiencing an outbreak of Rocky Mountain spotted fever. Over 40 cases were identified, and six children died of the disease.
Because it was in another country, there wasn’t a mechanism in place for the health center to hear about the outbreak – and to recognize the illness when it appeared in one of their facilities – even though it was happening less than a mile away.
“I’m a pediatrician. That really opened my eyes,” said Dr. Jonathan Melk, now the CEO of Chiricahua Community Health Centers, Inc., or CCHCI.
With the help of a new grant from the Pfizer Foundation and Direct Relief, Melk has ambitious plans to identify and treat the infectious diseases that are most prevalent in his community.
CCHCI serves Cochise County, a desert terrain dotted with small communities and agricultural homesteads. More than half of their patients live below the federal poverty line.
Like most of the world, the health center sees its fair share of chronic diseases: diabetes, hypertension, heart disease.
But Melk is equally concerned about another enemy, one that he’s seen affect too many of his patients: infectious disease, which just means anything that can be transmitted to humans, whether it’s an STI like gonorrhea or chlamydia, a respiratory ailment like tuberculosis, or a tick-borne illness like Rocky Mountain spotted fever.
Melk described seeing children with irreversible neurological symptoms in his health center due to infections that had gone unseen and untreated. Vaccine-preventable diseases like meningitis and Haemophilus influenza B.
The problem is that, where infectious diseases are concerned, “we’re in the mode of just trying to keep up all the time with the demand,” Melk said. “It’s time in our health center to proactively address infectious disease.”
That means, first and foremost, finding out what they’re up against. While Melk was able to speak anecdotally about what he and colleagues have seen, he’d prefer to be able to look more broadly and impartially at the issue, using data.
However, he said, physicians are generally trained to treat and report cases of most infectious diseases as one-off events – and that CCHCI doesn’t currently gather data on infectious diseases in its patient population that would help them better anticipate and meet patient needs.
The cliché is that “infectious diseases are from the developing world, that’s their problem, and chronic disease, that’s our problem,” he said. “And that is not the situation.”
A Varied Landscape
Melk, asked about the surrounding community, described a remarkably varied and disparate landscape. There’s the gentrifying artist’s colony, many of whose residents have been there since the 1960s. The agricultural border town, where more than a third of the population lives below the federal poverty line. What Melk describes a “second Amendment,” open-carry community. A military base that draws people from all over the world – Vietnam, Iraq, Korea.
CCHCI serves them all. “The towns are remarkably different from each other,” Melk said. “Every one of these places that we serve requires a different approach.”
To complicate matters, the area that CCHCI serves also shares 100 miles of border terrain with the Mexican state of Sonora. While the media tends to focus on permanent migration, Melk said border life involves a continual flow of people back and forth between the two countries.
“On any given day, there are thousands of people going back and forth, even now,” when mobility has been restricted because of Covid-19, he said.
That includes dozens of CCHCI’s staff, who live in Mexico with their families and commute across the border to work at the health center.
If Melk and his wife want to go see a movie, it’s just a few minutes to cross the border to a movie theater – as opposed to driving more than an hour into the hills of Arizona.
“We practice global health in the United States,” Melk said. “We live in one community that’s divided by an international border.”
Although the health center has nine fixed locations, the vast area they serve also requires them to be able to reach people an hour and a half away who might not otherwise have health care access.
To reach into remote areas of their rural county, CCHCI also operates a fleet of eight mobile clinics – six provide medical care, two dental.
And to make care more accessible to their diverse population, CCHCI hires directly from the communities it serves whenever possible – “We’re in the business of training people up,” Melk said – and does outreach via a dedicated group of community health workers, who are just as comfortable approaching a group of newly-arrived agricultural workers as they are hanging out in a superstore parking lot at 3 a.m. to enroll patients in primary care service or just ask how they can be of help.
That doesn’t just mean health care. Melk explained that CCHCI will make sure that patients have a functioning roof and that their electricity is turned on; that they’re not hungry; that their children are enrolled in school. They’ll help a patient in need move or find a job.
All told, the health center’s 350 employees served over 30,000 patients last year.
Greater Knowledge, Better Outcomes
But infectious diseases have proven an ongoing challenge for CCHCI. Clinicians are frequently surprised by the conditions that they routinely diagnose – some of which they had only seen in textbooks before coming to work at the health center.
Melk has ambitious plans for a new initiative, the Borderlands Infectious Disease Prevention Program, which will track and analyze incidence of infectious disease at the health center – with the goal of more effectively addressing patients’ needs and improving health outcomes.
Thanks to a grant from Direct Relief, that’s precisely what he’s planning to do.
“I think that, really, the bang for the buck is going to be to see what we’ve diagnosed,” as opposed to just relying on anecdotal reports from health center physicians, said Melk.
But it’s not about gathering academic knowledge.
Just treating incidents of disease as they arise is “going to get really discouraging and boring,” Melk said. “I would like to change some of these stats, and defeat some of them [so that] despite the poverty, despite the geographic isolation, you’re better off to live here.”
Planned-for outcomes after two years include an increase in community immunizations for children and adults alike, STI screening, and other preventive measures.
Despite the challenges, Melk is optimistic – and highly aware of Cochise County’s appeal.
“Border life, it’s a wonderful life to live. It is endlessly fascinating,” he said.