Mountain ranges with peaks soaring to 8,500 feet, historic buildings, golf courses, world-class birding, hiking, bicycling and an international flavor characterize Nogales, Arizona, and neighboring communities in Santa Cruz County, at the southern tip of Arizona.
Physicians are needed in Nogales and Santa Cruz County. Filling the regularly occurring vacancies is a challenge for medical directors at the area’s health center and the community hospital. That’s partly because small-town life doesn’t appeal to everyone. And in some cases, while the physician is happy with his or her choice, other family members can’t find the employment or family activities that metropolitan areas offer.
But doctors who’ve settled in the area find that since they’re 60 miles south of Tucson, Arizona, they can easily drive there - on an interstate that’s never congested - for theater and concerts, shopping and restaurants.
Joel Block, MD, who specializes in family practice at the Mariposa Community Health Center, describes himself and his family as adventurous and says they’re constantly finding new weekend hiking spots in the mountains that surround the area. He and his wife moved to Nogales in 1992 from Iowa. "My wife did not like the winters in Iowa," he explains.
With their two daughters, now ages 14 and 15, they’ve found a great home. Block has always noticed the intriguing mix of cultures and says he and his wife "were attracted to the international flavor on the border." Many residents are Hispanic, from areas in Mexico, "but all kinds of people are moving here."
The opportunity to observe migrating and resident birds drew Carol Hippenmeyer, MD, emergency room director at Carondelet Holy Cross Hospital.
"I trained at the University of Arizona and Stanford and lived in the Bay Area for a number of years, and prior to entering medicine, I was a birder," she explains. "So when I left the Bay Area and decided I wanted to pay off my student loans and couldn’t do that living in San Francisco, I decided to move back to Tucson."
She says Tucson was "too big" so she moved to Sonoita, south of Tucson and east of Nogales, "because I was familiar with the area from having been a birder." (The corridor through north Mexico and southern Arizona is a long-established migration route and there are many locales from which to watch birds - especially hummingbirds.)
Nogales was part of Mexico until the Gadsden Purchase of 1854. The unusual name came from the extensive spring-fed groves of native walnut ("nogales" in Spanish) trees growing in the vicinity. The glorious weather in this Sunbelt region is something that just about everyone appreciates. Although Nogales is within the Sonoran Desert, it’s not the dry, flat and sandy environment of other deserts. Rather, it’s hilly with plenty of hardy trees and shrubs. At an elevation of 3,865 feet, the summer heat is generally 10 degrees lower than Phoenix or Las Vegas. Winter days are mostly sun-filled, although in December and January some morning lows dip into the teens with average daily highs of 65.
Nogales is a small city, with a population of 21,785. Nearby unincorporated Rio Rico, with about 16,000 residents, is a few miles north. Santa Cruz County’s population is estimated at 45,245 and includes rural communities such as Tubac, Patagonia, Sonoita and Elgin. Incorporated on July 21, 1893, Nogales is located next to the identically named city of Nogales in the state of Sonora, Mexico. The area has been known as Ambos Nogales (or both Nogales) ever since that time and a strong flavor of Latin America spices the community on the U.S. side.
In Nogales, Arizona, sales tax paid by shoppers from Mexico maintains a healthy economy for this small city. Nogales, Sonora, Mexico has a population of approximately 400,000, and many of its residents enter the U.S. legally every day to work, shop or travel north to Tucson or Phoenix. Alternately, U.S. residents enjoy heading south for shopping, restaurants, nightclubs and music. Duty-free shops a half-block north of the border add another shopping dimension with liquor, cigarettes, perfume and other items.
Because the majority of residents are bilingual, the English-only speaker has no difficulty anywhere in the community. Hippenmayer says language hasn’t been a barrier in her work. Even though she arrived in June 2007 with some ability to speak Spanish, she’s found it could take years to have more confidence. "I think I speak Spanish, and then I hang out with the nurses here and I understand I really don’t speak Spanish at all," she laughs. "Every day I learn something new, which is kind of fun.
"The physicians who don’t speak Spanish don’t have any problem because we have translators and the staff. There’s always someone available, trained to translate," she says.
New facility, great opportunities
Hippenmayer’s employer, the 45-year-old Carondelet Holy Cross Hospital with 25 acute care beds, located just north of the U.S.-Mexico border, is scheduled to be replaced in the near future. The new facility will be built on land close to the retail center of the city, near stores such as Super Wal-Mart and Home Depot and a nine-screen movie theater. Groundbreaking is anticipated near the end of 2008, says Richard Polheber, the hospital’s chief executive officer. In the mean time, Carondelet is looking for the right person to fill its new hospitalist position, adding to the staff of 62 active and provisional physicians, 19 credentialed allied health professionals, 240 associates/employees, and 40 volunteers. The hospital currently offers a 24-hour emergency room, birthing services, diagnostic imaging services, laboratory, outpatient surgery and testing, rehabilitation, surgical services and women’s surgical services.
Dina Sanchez, assistant administrator, says, "We’ve started strong recruitment efforts. We’re finding it’s becoming more of a challenge for our local physicians to get away from their clinics, to get away from their family life, to treat patients in a hospital.
"We found that we were starting to see a trend of patients being sent to Tucson, so the management of patients could take place over there. In order to help with that situation, that’s how the hospitalist situation came about," Sanchez says.
Next door to the hospital at Carondelet Medical Group are the offices of three physicians and two family nurse practitioners. Many specialists from Tucson also visit on a regular schedule. Practice manager Mary Beth Klatt says she has been working for several months to fill a physician vacancy for a fourth physician.
With three locations, Mariposa Community Health Center is the largest primary health care provider on the Arizona/Mexico border. The staff includes 13 physicians and three nurse practitioners. Eladio Pereira, MD, medical director at Nogales’ Mariposa Community Health Center, says he has a vacancy at least once every year. The health center operates from two large side-by-side buildings in Nogales on Mariposa Road and opened a clinic in Rio Rico in September 2006, while the Patagonia Family Health Center, operated by the Mariposa Center, has been aiding residents of the rural east county area for many years.
Physician specialties include family practice, internal medicine, pediatrics and obstetrics/gynecology. A behavioral health specialist supports and assists the physicians. There is an affiliated dental program with three dentists. An award-winning health promotion component titled Platicamos Salud uses lay health workers who visit residents in their homes and teach about nutrition and healthy activities.
Another Nogales provider is Pima Heart, which has one full-time internal medicine physician, a part-time cardiologist, and a nurse practitioner. Based in Tucson, it was founded in 1981 and has seven satellite locations, including Nogales.
There are three independent physicians in Nogales, including two obstetricians/gynecologists and a pediatrician. The Tubac Regional Health Center, a small family practice center 20 miles north of Nogales, is operated by the non-profit Tubac Health Care Foundation and employs just one physician.
An advantage to working on the border is the connection that physicians make with their patients - and the Hispanic culture fosters that bond. Hippenmeyer says she’s grateful to get to know local residents. "The patient population here is universally thankful, universally polite, and after having worked in big cities, I can tell you it’s really nice. You may have a couple days out of the month that you really earn your keep - it’s busy, it’s crazy. But there are ample opportunities to sit and talk to a family member or with relatives out of town on the phone," she explains. "You really do have the opportunity to communicate with patients. For me, that’s a real plus."
Of course, nothing’s perfect and Hippenmeyer says she deals with problems due to limited capacity. "There are definitely frustrations. It’s difficult to work in a smaller hospital because all the sub-specialty support services the patients now come to expect are simply not available. We feel the burden of our responsibilities to our physicians and patients. It’s a difficult job to be the only health care provider.
"We do have mass casualty protocol in place. That’s part of increasing the ancillary services responses. We don’t close, we don’t go on divert. We don’t turn people away because we’ve exceeded the capabilities of the institution. We just keep calling people in. Blessedly, that doesn’t happen very often," she says.
Pereira has contended with similar problems. "You need to have a high level of confidence in your clinical skills because you don’t have technology readily available. You may, but in some cases you don’t. Paying attention to the history and the physical exams are essential."
Although a rural location can bring professional dilemmas for physicians, the Mariposa Community Health Center is progressive in certain areas. For example, telemedicine is used regularly to communicate with University Medical Center in Tucson.
Telemedicine "also adds a new level of contact with specialists. If you consult with a specialist, he or she will know you and clinical ideas are exchanged and hopefully that will create trust with each other. I think that exchange is pretty unique. Not very often do you have the chronic care provider and the consultant specialist talking about the problem," Pereira says.
Education in Nogales and Rio Rico is held to the same state standards as Phoenix and Tucson schools, but with 85 percent of the students being Hispanic - many of whom don’t begin to speak English until kindergarten - there are separate challenges.
Block says he and his wife home-schooled their daughters but when they were old enough for high school, each chose a different local school based on unique offerings at the campus. The two largest public school districts include Nogales with one 1,800-student high school, two middle schools, and six elementary schools; and Rio Rico, where the Santa Cruz Valley Unified School District No. 35 has one 1,200-student high school, one middle school and three elementary schools. About 20 miles east of Nogales, Patagonia Union High School has just 90 students.
Post-secondary education opportunities are offered by the affordable Cochise College, which focuses on classes that prepare individuals to transfer to a state university. Transferable degrees and workforce training are available at several locations although there is no dedicated campus. Northern Arizona University, based in Flagstaff, Ariz., has classes in Nogales, and there’s a small campus of the private University of Phoenix.
Individuals who only have heard about border areas from the media might be worried about drug smuggling and illegal immigrants. However, very little touches the community. There are drug smugglers, says Santa Cruz County Sheriff Tony Estrada, but "it’s a safe county and community. There are probably more law enforcement officers here per capita than anywhere else," he says.
He’s observed what he calls the "trampoline effect," in that drug smugglers want to get their contraband from Mexico to Tucson and so it bounces over Nogales. He says the crime rate is about the same for any small town and the occasional violent crime occurs when people know each other, just as in other communities.
Hippenmeyer echoes that. "I don’t live in Nogales, but I have never locked my doors" at her home 30 miles east. "I don’t fear for anything. I frequently leave the hospital at 11 p.m. or 6 a.m. and it’s never been an issue for me. I think any institution has to have a modicum of security because we’re responsible for our patients and our staff, but I don’t have any issues living or working in Santa Cruz County and don’t know anyone who does.
"I think you hear about (potential danger) because border issues are a hot topic."
The great outdoors is an advantage that residents don’t take lightly. Hiking trails in the Santa Rita Mountains which head up to the 8,585-peak of Mount Hopkins and the nearby 7,000-foot Mt. Wrightson, located at the north edge of Santa Cruz County, offer great workouts.
About six miles west of Rio Rico, Atascosa Peak at 6,299 feet boasts views south to Mexico and north to Tucson. The Juan Bautista de Anza National Historic Trail, which will link Nogales and San Francisco, California, has been open in segments in Tubac, Tumacacori and Rio Rico for 10 years. This level trail parallels the Santa Cruz River. Two fishing lakes are located in the county, Patagonia Lake State Park and Peña Blanca Lake. Visitors explore area ghost towns left over from silver mining enterprises in the late 1800s.
Santa Cruz County’s golf courses are top-notch. To the northwest in Tubac is the 27-hole Tubac Golf Resort where portions of the Kevin Costner golf film, "Tin Cup," were filmed. The Rio Rico Golf Course in that community, the Palo Duro Golf Course in Nogales and the Kino Springs Golf Course east of Nogales all offer great facilities. The retirement community of Green Valley, 45 miles north of Nogales, has 10 courses, a mix of public and private.
Ocean access to Mexico’s Gulf of California is a four-hour drive south, where San Carlos, Kino Bay and Guaymas entice tourists.
Rio Rico, or "Rich River," is Nogales’ largest neighboring community, with 16,000 residents. Once part of a vast land grant from the King of Spain, now a hilltop resort hotel looks over the legions of suburban homes. A little farther away is Tubac - 20 miles north of Nogales and 40 miles south of Tucson - a town where art and history meet; it’s a shopping Mecca featuring 100 boutique stores, art galleries and restaurants on narrow streets perfect for strolling. Arizona’s first state park, on the site of an historic Spanish presidio, or fort, also is located in Tubac.
All of these offerings are appealing to many who settle here, according to Carondelet’s assistant administrator, Sanchez, but it’s the work that offers the largest reward.
"I think the biggest thing I hear over and over again is that [doctors] enjoy coming to this community because they feel they’re making a difference," she says. "I do hear many physicians say that they come to this area because it’s small. It’s a very close-knit community. The patients they serve are very appreciative of what they do. To them, that’s very rewarding."
Small town life isn’t for everyone, but there are always those who will embrace the challenges and idiosyncracies, and Carondelet’s Hippenmeyer is among them. "I’ve practiced rural medicine for a long time. I don’t have to, I choose to," she says. "And we would prefer to have physicians here who choose to practice in a rural environment." end
Kathleen Vandervoet, a freelance writer, has lived in Santa Cruz County in the rural community of Tubac since 1978.