House Calls with John
evenings, were for upper respiratory infections, skin infections, vomiting and diarrhea, ear infections, or high fevers of unknown origin.
During one house call, I dropped my stethoscope next to the sick child's bed. As I stooped to pick it up, I glanced at the bedsprings and was surprised to see a dozen black widow spiders and their nests. I suggested that when the child was ambulatory, the parents should sweep out the spiders.
On another house call, I noticed a large bottle of Pepsi-Cola in the refrigerator. It was a favorite beverage for many families in that hot climate. I explained that soft drinks are not a wise way to satisfy thirst, that ordinary water is much healthier and not nearly as expensive. Such teaching was an important element of house calls.
Our house calls also made us aware of environmental problems. Frequently I saw patients who had developed sudden asthmatic attacks when planes spraying pesticides flew too close to their homes.
In addition, I became aware of the efforts of César Chavez and the United Farm Workers union to improve the lives of migrant workers. We'd been in the Imperial Valley for three years when César sent a recruiter to our home in Brawley. He invited me to help establish a union-funded clinic near Fresno, in the San Joaquin Valley. I admired César's non-violent approach and decided that working with him would be a privilege.
While the search for a clinic site was in progress, the Fresno Bee reported that "the first case of polio in a decade took the life of an Avenal farmworker." César's office called and asked us to investigate the death, suspecting it might have another cause—possibly even pesticide exposure. A colleague and I drove to Hanford, about 40 miles west, and met with the doctor who had made the diagnosis. He was a retired pathologist who maintained a microscope in his office. He showed us his slides, which demonstrated marked nerve-cell damage in the pons, deep within the brain. He commented, "I have never seen such a rapid onset in a previously healthy man or such marked nerve-cell destruction with
polio, but I am open to suggestions." We told him that we intended to visit the home of the man who had died, a plan that he encouraged.
The deceased, according to fellow workers, had been planting melon seeds treated with Thiodan fungicide and Dieldrin insecticide. The men handled these seeds with bare hands, and the "polio" patient had padded his metal tractor seat with the empty burlap bags the seeds had been stored in. We visited his home and took samples of rice, tortillas, beans, cooking oil, and pastries in case they were needed for analysis. En route home, we stopped to talk again with the doctor, who had prepared more slides for analysis and was willing to assist us in any way possible. I asked him to forward a few slides to a pathologist at UCLA Medical Center—someone I had known in Rochester. "He is especially interested in neurologic problems," I explained. The doctor said he'd be happy to send along the requested specimens.
Later, I studied the pathology of Thiodan and Dieldrin, both of which can be readily absorbed through the skin. I learned that the brain findings were more consistent with a toxin exposure than with an infectious disease such as polio. Ultimately, a definitive diagnosis from the Los Angeles pathologist corroborated that suspicion.
In May 1973, I testified before the California Workmen's Compensation Board regarding the use of the short hoe—known as "El Diablo" by the workers. Less than 17 inches long, it required farmworkers to stoop all day as they were thinning or weeding lettuce. Crew bosses
could easily spot workers who stood to ease the strain on their backs. Those who stood too many times were dismissed from their jobs.
Growers insisted that the short hoe was the only way to properly care for lettuce. Those of us who testified on behalf of the workers showed x-ray data and described workers incapacitated by permanent changes in their vertebrae after only a few years of the constant bending. But the workers themselves were the best testimony. One older worker demonstrated the position required to use the short hoe compared to a long-handled hoe. He also demonstrated the post-work position of the back at the end of a long day in the fields. Shortly after the hearings, California prohibited the use of the short hoe, a wonderful victory for the workers.
Yet despite my pride at being part of such efforts, by the end of 1975 I had reached a burn-out state. The fatigue was physical, psychological, and economic (since I was essentially a volunteer for the union; Dotty and I got an allowance for an apartment, gas for business use of our car, and $25 a week). Although I admired César Chavez, it was time to move on. Over the next seven years, I worked at a clinic serving farmworkers in Woodburn, Ore. (which closed due to loss of its funding); at a network of three neighborhood health centers in Pueblo, Colo. (where administrative problems drove many staff—including me—to leave); at a clinic in Greeley, Colo. (where administration was again a problem); and at an urban community health center in San Jose, Calif. (from which both the medical director and I were fired when a new director decided to start with a clean slate). Such were the vicissitudes of working in this underfunded arena. But by this time, I had added board certi- fication in family medicine to my credentials in pediatrics, opening up additional opportunities.
In 1982, I was offered an associate clinical professorship in Stanford Medical School's Department of Community and Family Medicine. I would teach part time in the family practice residency at San Jose Hospital and oversee the preceptor program for first-year medical students.