On a recent flight across the country, I found myself staring out the window at a vast desert landscape that, as the crow flies, is a relatively short distance from the crowded streets of sprawling Los Angeles.
From the air, it was possible to see towns and small cities in their entirety — squat buildings hanging out around a single intersection or rows of identical houses marching in tight grids alongside patches of sprinkler-fed green. Human-scale homes, post offices, local markets and cafes were dwarfed by the influx of massive, white rectangular warehouses parked along the highways like cruise ships along a canal. It was easy to eyeball the distance from one cluster of structures to the next, to trace the tenuous arterial connections of lonely roads leading from one beating heart to another.
My vantage point gave me a “big picture” sense that felt akin to the broad statements being made about the state of our country. For instance, I knew from reading a recent study by The Commonwealth Fund that the U.S. “continues to be in a class by itself in the underperformance of its healthcare sector,” but I didn’t have a great idea of how or why the health system in one of the wealthiest countries in the world could rank dead last among 10 comparably wealthy countries and 69th internationally.
Our rural areas, places many of us often see from a great height or at great speeds as we are on our way elsewhere, feel the brunt of this deficiency. According to the National Center for Health Statistics, rural mortality rates in 2019 were 20% higher than in urban areas. Rates of leading causes of death — such as heart disease, cancer, unintentional injuries, and chronic respiratory disease — are also much higher in rural areas.
There are plenty of reasons to live far from the city: lower housing costs, employment opportunities, family connections, a need for privacy, the desire to look up at night and see a sky full of stars. Whether they are there by choice or by chance, all residents are owed basic rights to the pursuit of happiness in a place with clean water, clean air, affordable housing, employment, and health care.
Cooper Lahti, left, a Claremont McKenna College student, and Pedro Lezama-Garcia, a UC Riverside student, share a laugh with a client as they volunteer at the Vineland Free Clinic in Riverside on Saturday, Oct. 12, 2024. (Photo by Mindy Schauer, Orange County Register/SCNG)
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I grew up in the mountains outside of Albuquerque, New Mexico — an experience that has given me, among other things, respect for the scarcity of water, the danger of fire, and the amount of time and fuel required when the nearest services are about 40 minutes away. I’ve got family and friends all over this country of ours, and recently, I’ve been talking with them about their experiences with health care.
I could write a book about the uncle who, after inadvertently shooting himself in the leg with a nail gun while climbing down a rickety ladder, had to take a ferry off Washington Island, Wisconsin, and drive two hours to Green Bay before finding someone to remove the nail. “All the local place can do is stitch you up or offer some antibiotics,” he said.
Out in Newell, South Dakota, my aunt, Jennifer Orwick, her husband and their boys, run a cattle ranch. Fourteen years ago, when her husband was diagnosed with cancer, they began making at least twice yearly trips to Rochester, Minnesota, for treatment. “It’s not a problem for us,” she said. “But I could see it as a problem for others. It’s 646 miles from here.”
For Ruth Nolan, an educator and writer in the Inland Empire, the rapid development and vacation rental explosion in the Coachella Valley has been coupled with a long, slow slide toward greater dysfunction.
“The amount of patients has quadrupled, wait times in the ER are 8 to 12 hours, you have to book a standard appointment months in advance,” she said.
She explained that the major influx of part-time residents adds pressure to those who “aren’t here for adventure, they’re here because they can’t afford anyplace else.”
There was an edge of anger in Nolan’s voice, but also of vulnerability, and I heard it again when I spoke to my friend, Windra Trujillo, MSN, R.N., a clinical educator in Albuquerque. She’d recently finished a de-escalation and self-defense training module for care providers.
“Why do I have to teach a doctor or nurse or EMT how to defend themselves at work?” She answered her own question by describing the barrage of personal attacks she’d sustained during her time as a bedside nurse. “Patients are coming in angry because they don’t have access and they’re in the emergency room and they are waiting too long and there’s not enough workers and that anger and frustration gets showered down.”
In Kentucky, my post-college roommate, Jennie Jean Davidson, is the director of Neighborhood House, a community center in West Louisville, an area hard hit by our nation’s twin forces of destruction, the opioid epidemic and the gun-violence crisis.
“Try to find a therapist of any kind — physical therapy, speech therapy, talk therapy, you name it,” she said. “There’s nothing.” She took a deep breath and sighed it out. “But I don’t like to spend a ton of time on the problem, my mind is always headed toward what’s the answer.”
In every conversation, the issues were the same: provider shortages, lack of access to health care, lack of preventative care, and vast inequities that can be traced to race, gender, income and ability. The problem is so large in scope, it is difficult to hold. But, like my friend, Jennie Jean, says, the secret is to try not to get overwhelmed by the enormity, but instead, look for ways to make a change. Who else is thinking this way? Who and what is being left out of the big picture?
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These are central questions for the community-based UC Riverside Medical School. With a stated mission to break down barriers of equity and inclusion, and train a diverse workforce to deliver clinical care and research to the Inland Empire, it’s the first public MD degree granting medical school to open in California in over four decades.
One of the fastest-growing regions in the state, the Inland Empire hosts a population of over 4 million (roughly as many as live in the state of Kentucky). Scattered over 27,000 miles of Riverside and San Bernardino counties and nearly 50% Latino/Hispanic, it is the fifth-largest Latino community in the United States. There are just 40 primary care physicians per 100,000 people, roughly half of what’s needed to provide optimal care. Specialty care is minimal.
The area’s problems mirror those found across the country in one rural area after another, but what sets the Inland Empire apart is its proximity to the enormous metropolis that is Los Angeles.
“As a region, we have some of the poorest outcomes in the wealthiest state,” says Anne vanGarsse, M.D., associate dean of Clinical Medical Education at UCR’s School of Medicine. She cites rising diabetes, respiratory illness, and lack of preventative care, along with poor air quality and increasing pollution as some of the urgent issues the school is working to address through research, education and services.
For vanGarsse, each student is a potential “agent of change,” and the school is focused on all aspects of their development. “We teach them that they are leaders even if they aren’t doing that formally. We try to build that servant/leader, servant/advocate thread into them as they are weaving the fabric of who they are as physicians.”
Starting in 2013 with just 50 students, UCR’s School of Medicine received more than 6,000 applicants in 2023. Just 86 were accepted, 73% of whom have ties to the Inland Empire and 44% percent of whom are from under-represented groups. Many current students are the first in their family to receive an undergraduate degree and, for many, English is a second language. It’s all part of the mission that in July landed the school in the seventh spot for diversity in U.S. News & World Report’s annual Best Medical Schools rankings.
“One of our main missions,” van Garsse said, “is to solve a workforce problem.”
Medical students volunteer at Vineland Free Clinic in Riverside where David Williams examines a patient while Sahithi Malireddy holds the unhoused women’s dog. UC Riverside pre-med student, Pedro Lezama-Garcia, is back left. (Photo by Mindy Schauer, Orange County Register/SCNG)
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Across our nation, medical providers are aging out of the profession or leaving due to stress or burnout. Recently published projections, by the Association of American Medical Colleges (AAMC), predict the United States will face a shortage of up to 86,000 physicians by 2036. In the accompanying report, AAMC President and CEO David J. Skorton, MD stresses that “sustained and increased investments in training new physicians are critical to mitigating projected shortfalls of doctors needed to meet the healthcare needs of our country.”
Skorton argues in favor of bi-partisan support for the funding of medical training programs. “Medical schools have done their part by increasing enrollment by nearly 40% since 2002. We must now expand graduate medical education so we are training more doctors to meet the nation’s healthcare needs.”
Though our nation’s communities share many of the same needs, it’s important to recognize the affect of local variables. In Newell, South Dakota, for instance, my aunt Jennifer stresses the possibility of rattlesnake bites and tractor accidents. “What we do out here is all high risk,” she said. “Because we’re working with machinery and animals … a lot can happen.” Icy Dakota winters may necessitate meeting the local volunteer ambulance at the end of a long dirt road.
While rattlesnake bites may be a threat in some parts of San Bernardino County, the larger issue is air quality. Given the grade of “F” by the American Lung Association’s 2024 State of the Air report, the county has the worst ozone pollution in the nation. All those enormous warehouses mean fleets of delivery trucks, and the burning of gallons and gallons of diesel fuel. Ozone gas causes inflammation and damage in the lungs and, ultimately, it can impact all body systems. Drought and the re-routing of the Colorado River are some of the causes contributing to the rapidly disappearing Salton Sea. The increasing presence of air-borne particulates released by the drying seabed have also contributed to an increase in respiratory ailments, including childhood asthma.
At the UCR BREATHE Center, a multidisciplinary collaborative for studies Bridging Regional Ecology, Aerosolized Toxins, and Health Effects, scientists, physicians and students with the UCR School of Medicine are simultaneously researching the causes of illness and finding new ways to treat the symptoms. Partnering with outside experts and faculty members in engineering, agriculture, biology and public policy, BREATHE seeks to understand the Inland Empire through regional climate modeling, studies on air quality and environmental justice and health disparities, and the health impacts of aerosolized particles, which include not only pollutants, but also pollen from invasive plant species.
“Everything is interconnected,” said Marina Zakhary Gad el Sayed, a second-year medical student at the UCR SOM. “You can’t mention the social determinants of health without eventually landing on the Salton Sea, diabetes, medications…”
Medical student Marina Zakhary Gad El Sayed is pictured at the School of Medicine Education building at UC Riverside in Riverside on Wednesday, Oct. 16, 2024. Gad el Sayed moved with her family from Egypt to Rancho Cucamonga, and had a positive experience with the UCR healthcare system led directly to her interest in becoming a physician.(Photo by Leonard Ortiz, Orange County Register/SCNG)
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Gad el Sayed, who, just before starting high school, moved with her family from Egypt to Rancho Cucamonga, has a personal understanding of correlation. Her own positive experience with the UCR healthcare system led directly to her interest in becoming a physician.
“I was a groggy teenager with uncertainty about what was going on in my body,” she said. “My doctor reassured me and my parents, who were English learners, and even entertained my young siblings because we had no one to leave them with.”
Eventually diagnosed with the autoimmune disorder Lupus, Gad el Sayed recounts how comforting it was to feel that her doctor was truly focused on her and her family.
In her first year of medical school, participation on “the wards” in the Longitudinal Ambulatory Care Experience (LACE) gave Gad el Sayed and her classmates an immediate connection with people living around her. Because the school does not have its own hospital, students are sent out into the various clinics and other hospitals in the area where, overseen by a mentor physician, they participate in all aspects of care.
“You don’t just learn the science,” she said, “you learn how it affects people in the real world.”
For students and volunteers alike, working in a wide variety of clinics and hospitals provides valuable insight not only about modes of practice, but also universally applicable lessons in humility.
“They are learning something that most physicians didn’t learn until later in our careers,” says Anne vanGarsse. “If you’ve seen one hospital, you’ve seen one hospital. Different places do things differently and yet they all get to the same result. That’s a big learning thing: don’t get entrenched in the idea of the way.”
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This kind of training also serves as a reminder that when individuals share resources, often the whole group will rise. In Albuquerque, Windra Trujillo, M.S.N., R.N., cast back to the earliest part of the pandemic when she was pulled out of the classroom and back into clinical practice. At first, hospitals siloed their resources, she remembered, but the educators were the first to change this behavior.
“We need to break down those walls of this is just a ‘my systems’ problem,” she said. “It’s not. How do we help each other serve our community? It’s not, who is better? It’s how do we make everyone better.”
Jason Sacdalan, MD, a family practice physician at Kaiser Riverside, has been working with the LACE program for nearly 10 years. It’s a volunteer position that runs parallel with his work at the hospital.
“I’ve been around so long some of my patients are very comfortable with students,” he said. “They feel like they are giving back to the community when they can teach students because they are literally teaching the future.”
Say “the future,” and it’s easy for me to picture a vast, unknowable landscape stretching all the way to the horizon. The enormity can feel paralyzing. “Future” is a word that can easily be shaded dark or bright depending upon the point of view of the speaker. It’s a word that those in charge like to use to remind us just how in charge they are. But, the more people I spoke to, the more certain I was that the job of defining our future belongs to all of us. As we make choices about how to spend our money, time and energy, we are moving forward together, one day at a time.
Intention is crucial.
“If you’re not intentional, then inertia will lead to a lot of other places,” said Denise Martinez, MD, professor of family medicine and associate dean of Diversity, Equity, and Inclusion at UCR’s SOM. Born and raised in the Inland Empire, she believes the school should mirror the community.
“We need more people to understand the language and the culture,” she said.
Though California is about 40% Latino, only 6% of the state’s physicians are Latino and just 2% Latina, making Martinez unique among her medical peers. Nationally, the numbers of underrepresented practicing physicians are similarly low. A 2021 study by the AAMC claims gender and racial diversity are on the rise in the U.S. physician workforce, while reporting that just 6.9% identify as being of Hispanic, Latino or Spanish descent, 5.7% Black or African American, and under 1% American Indian or Alaskan Native.
To put this disparity into perspective, according to the AAMC, out of 841,342 active physicians, just 2,583 identify as American Indian or Alaskan Native. Recent census reports show 9.7 million people in the U.S. identify as American Indian or Alaska Native. With so few direct role models, just a handful of young people might be inspired to pursue a career in medicine.
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At UCR’s SOM, the aptly named Pathway Programs offers myriad opportunities for high school and college-aged students to see themselves as part of the healthcare system. With 10 programs in action, Pathway works to recruit a diverse cohort for the medical school, but also to create opportunities for all young residents to expand their skills and broaden their horizons.
For Jalene Rodriguez, who has been admitted to the School of Medicine for fall 2025, Pathway has been invaluable. “I was born and raised in Riverside. I am a first-generation Latina student and I hold great pride in that title specifically,” she said.
Prior to her freshman year at UC Riverside, Rodriguez participated in Jump Start where she was paired with upper-level mentors who helped prepare her for the rigors of college life. As an undergrad in the Medical Scholars program, she was introduced to a network of peers and professionals and received coaching on interviewing, resume writing and advocacy.
“I was scared of this path because I didn’t know anyone who looked like me that was on this path,” she said.
Pedro Lezama-Garcia’s parents immigrated to the Coachella Valley from Mexico, and he grew up helping them in their Mexican food and bakery business. As an eighth grader participating in Kaiser Permanente’s Hippocrates Circle, he learned about the UCR SOM Pathway Programs. As a high school freshman, he joined Pathway’s Medical Leaders of Tomorrow.
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A single week in the program spent living and learning on the UC Riverside campus inspired him to apply to UCR. He is now a third-year undergrad, volunteering at both the Coachella Valley Free Clinic and Inland Vineyard Free Clinic.
“I always saw my parents struggle at doctors’ visits with their limited English,” he said. “The only support they had was me. Even then, I struggled to translate complicated medical terminology. However, bridging the barriers is only one part of the answer. Understanding the cultural differences and valuing everyone’s unique cultural background plays a huge role in personalized healthcare treatments.”
Offering these students a chance to act as a bridge between people and healthcare providers improves communication, can assist patients in learning to self-advocate, and builds another layer of attentiveness into what should always be a caring system.
“It’s not a bunch of big medical machines, it’s not an expensive drug trial,” said Jennie Jean Davidson, director of Neighborhood House. “It’s people talking to people. It’s showing those young people a path to a medical career, but it’s also showing them the true path to goodness, which is social work.”
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On my recent flight across the country, it turned out that the man next to me was a cardiologist from Sherman Oaks who spent a fair amount of time volunteering at various clinics in rural Los Angeles County.
“Money and egos,” was his answer to my question about the biggest problems with health care in the United States. It was a good answer, but it’s not the only answer. Sometimes, in the dead of night, my brain reels with additions to the list: environmental degradation, racial and economic disparity, crumbling infrastructure, food deserts…
The list is long.
Just as lengthy, though, is the roster of those working to find solutions: those unpaid ambulance drivers my Aunt Jennifer refers to as “saints and angels,” the 1,000-plus physicians and professional volunteers who mentor and teach students in the UCR Pathway programs, and also the professors and administrators at the UCR School of Medicine who have made it their mission to hold the door open for a new generation of doctors.
I think about the way everyone I spoke with for this story acknowledged the big issues and still found a way to look beyond them; to draw from their own skills and talents and life experience to try to make a difference.
From the air, it’s possible to see the edges of the big cities and the dividing lines of fences and walls and interstate highways, but down here, on the ground, we are all part of the big picture.