Chapter 1. The Great Hope 1970-1978

War on Poverty Comes to Tucson............................. 2

Philosophy of the Clinic............................................. 12

The Community Board.............................................. 14

Training People for New Jobs.................................... 18

National Health Service Corp.................................... 20

The Team Approach................................................. 21

The Magnificent Seven............................................. 24

Board-Staff-Patient Relationships............................... 29

An HMO Comes to El Rio......................................... 36

The El Rio Facilities................................................. 39

Physical Area Covered............................................. 43

Design of the New Facility....................................... 44

In the Community.................................................... 45

Chapter 1. The Great Hope . . . 1970-1978

War on Poverty Comes to Tucson

In the mid-1960's, President Lyndon B. Johnson began to establish federal anti-poverty programs as part of his war on poverty. Projects like Medicare and Medicaid began at that time. National leaders, wise enough to recognize that many of the poor did not create their own poverty, supported programs which helped mobilized citizens, organizations and institutions for the purpose of enhancing opportunities for unfortunate communities. National and local government agencies pooled resources with those of private agencies and helped develop new coalitions so that the poor might gain a voice in developments that affected their communities. Two such nationally supported projects, the Model Cities Program and a program to improve health care services, came to Tucson in the late 1960's. Even though many of the enterprises which started at this time suffered eventually cuts, either as victims of the war in Vietnam or later during the administration of President Ronald Reagan, a process of change had begun in Tucson. In the early 1970's, a few of the poorer neighborhoods in Tucson, Arizona bustled with the hope of reducing some of the more odious and painful impacts of poverty.

Ideally, the Model Cities Program of Tucson aimed at reducing poverty by providing broad, integrated services involving job training programs, educational opportunities, up grading neighborhoods through home repair activities, housing sanitation and developing health facilities. This program aimed at developing a committed partnership between the residents of the community and local government, business and community activists. Many of the Model Cities Program objectives also affected public health.*

In Tucson, the Model Cities Program primarily covered the people living to the south and west of downtown in an area divided geographically into six units. People within each of these units met frequently among themselves and also with people from the University of Arizona, Pima Community College, school districts, local governments and with other interested folks.

They came together to begin to resolve their neighborhood problems. In the process they began to know each other quite well and this played a positive role in future developments in the planning and development of a new community health care facility.

Herb Abrams, MD, who is considered by many as "The Father of El Rio," remembered that "it was a hopeful time." Federal funds became available for the formation of neighborhood health centers controlled by the people they served. He remembered this time as,

"...a great experience in democracy. We met several nights a week in schools, churches and other public buildings. There were intense discussions far into the night about how the Center should be organized, where it should be located and how the policy board should be constituted."

*Those objectives sought (1) to reduce illness caused by poor sanitation through the construction of indoor plumbing and sewage facilities, (2) the elimination of hunger through increased access to food and an improved system of nutritional education, (3) to reduce illegitimacy, birth rates, premature birth and also infant mortality and morbidity, (4) mental health services which would be directed toward the needs of the community, which included treatment for drug and alcohol abuse, (5) to utilize the local county hospital which would provide services responsive to the needs of the community, (6) to explore the possibility of making available prepaid comprehensive health insurance, (7) to have vigorous outreach efforts to reach the community residents, (8) to increase the number of neighborhood residents in health career positions so that they would be able to serve as a bridge between people of the community and health care professionals, and (9) to better understand the underpinnings of some of the health problems and the resident's perceptions of those problems.

Abrams had come to Tucson in July of 1968 from Chicago where he had been Professor and Chairman of the Department of Preventive Medicine at the Chicago Medical School and also as Director of the Outpatient Clinics at the Mt. Sinai Hospital. In Chicago, Abrams had organized a neighborhood health center which came to be known as the Martin Luther King Health Center. He had also organized and directed the Union Health Service in Chicago, which was sponsored by several unions. In Tucson, he worked toward a twofold mission: (1) to establish a Department of Community Medicine at the new University of Arizona Medical Center, and (2) to organize a neighborhood health center in a poverty area of Tucson. The community oriented neighborhood health center emphasized family practice. So, Dr. Abrams played a major role at the start of the new clinic which would be known at the El Rio Neighborhood Health Center or simply as "El Rio." As part of the war on poverty, Congress passed legislation enabling funding of a grant written by Abrams for a neighborhood health center.

In her paper, "What conditions led El Rio NHC employees to unionize?" Mary Lou Gonzales, an El Rio family nurse practitioner who had been recruited by Abrams, recalled that in 1969, Abrams, wrote the original grant proposal to provide comprehensive health care for the residents of the original Model Cities units. Mary Lou Gonzales wrote:

"This area was found to be underserved in health care. Most of the residents over utilized emergency rooms for episodic care, the only clinics for prevention were the well-baby clinics, prenatal clinics, and family planning clinics of the Pima County Health Department. This type of care was fragmented."

El Rio, initially functioned under the administration of the University of Arizona and this lasted for almost five years. The two entities, El Rio and the University of Arizona, separated on June 1, 1974. When the University of Arizona sponsorship ended, employees lost some pension benefits but maintained access to the monies already contributed.

Jessie Reece, El Rio's first employee, remembered the loss because the employees had not yet been vested in the full five years. Reece, a quiet, stately, African-American young woman in search of a job to maintain herself and her young daughter worked for a business man, Hubert Davis. Davis sold his small business and knew about the El Rio grant so he suggested that Reece contact Abrams. Reece had not been a social activist and had not been involved in social change although the concept of the clinic initially tended to attract social activists. In the summer of 1969, Abrams hired Reece. Shortly afterwards, Abrams hired El Rio's second employee, Mr. Y. B. Rhee, of Korean descent, to serve as El Rio's first administrator. Rhee began his employment in September 1969 about 18 months before the clinic opened.

Rhee interviewed Reece, who already had been hired, and accepted her as his secretary. Reece thought of Rhee as a knowledgeable and sensitive individual. Rhee and his family maintained contact with Reece for many years after leaving the clinic. This contact lasted well into the 1990's.

As the concept underlying El Rio developed, people from Model Cities assumed three key roles. First, their outreach efforts resulted in the community's acceptance of a new clinic and of the services that the clinic could offer. Second, many of these people served as members on El Rio's Board of Directors. And third, much of the staff came from the community.

Numerous workshops and task force meetings grew into better understandings of the community's perceptions of health problems in their neighborhood. Residents stated more than twenty-five health problems at those meetings. Many of them revolved around economic issues: "dentists are too expensive," "there is not enough money for medicines," and "can't get an ambulance if you don't have money." In addition, many of the complaints directed at the establishment included: "accident compensation too low," "health benefits are removed when you get a raise," "city and county money spent on the wrong things," and "health volunteers are never at Pima County Hospital where they are really needed."

People from the broader community also expressed hostilities. In a 1994 interview for the Arizona Historical Society, Abrams told of the animosity toward the establishment of El Rio. The animosity mainly came from a few physicians in private practice who thought of El Rio as a "communist" enterprise or at least "socialized medicine." They feared competition from the health facility. Some pharmacists and dentists expressed the same concerns. Because of their apprehensions, Abrams found himself attending a myriad of meetings to reassure those health care providers.

Years later, Dr. Herb Abrams recalled some of the problems faced in setting up a new clinic:

"When those of us from the medical school first approached the southwest side community, in the barrios, with the idea of establishing a health center in their midst, we were often met with reserve if not with frank suspicion. Who were these interlopers from the east side? The community had already been negatively conditioned by housing removal to make way for the community center. Now comes that colossus, the University, with more ideas. Do they want to experiment on us? Our job was to persuade people that they had an opportunity to build and run their own health center.

And on another level, we had to reassure many of the doctors, dentists and pharmacists in the community that this wasn't the boggy man --socialized medicine.

Today, 20 years later, El Rio is thriving."

Several people who worked in the war on poverty, among them Alicia Tovar, Julia Soto and Dolores Elenez, later became employees of the new clinic.

Alicia Tovar, who worked as a paid "community aide" in the Model Cities Program, recalled sitting at a Model Cities meeting and conversing with Dr. Abrams who also attended many of those meetings. Abrams informed Tovar about the new jobs at a community health care facility that would become available. The idea of working at El Rio excited Tovar as she saw it as a new adventure.

Tovar a young, intelligent, sensitive, self-motivated woman knew of the many problems of the people of her community. She felt a strong concern for social justice. Well educated on the nuances of social issues, Alicia's formal education consisted mainly of high school and a few courses at the local community college. Her job as community aide involved going from door to door to get the word out to the community about the emerging programs. The aides sought to elicit ideas from the community to determine the issues.

Tovar's activism went back to her high school days. Students at Tucson High School decided to walk out over an issue which is now long forgotten. Tovar, not too familiar with the issues, still joined those students that walked out. A local activist, Salomon Baldenegro, had organized the walk out. At this event, Tovar met Baldenegro someone who would have a profound effect on the clinic.

Julia Soto was another employee who worked for Model Cities before coming to El Rio. Both Soto and Tovar, among the earliest employees to be hired, developed reputations as fierce advocates for their constituents. When employed by El Rio, Soto worked as a patient advocate while Tovar started as a clerical worker. Soto remained at El Rio many years and over time came to share the vision of changing El Rio administrations. This eventually put her at odds with many employees.

Dolores Elenez, a young woman in living in the Yaqui Indian community, also first became aware of the concept of a community health center through her work with the Tucson Model Cities Program. Elenez remembered folks involved with the Model Cities Program got together almost daily. They discussed the prospects of a community clinic and what that clinic should be like. Elenez recalled that through this program people began to push for a community health center. At that time, the concept "community health center" optimistically portrayed a distant ideal. As the dream matured into reality, some of the people involved with that effort later became the first members of the Board of Directors. So, Elenez first encountered El Rio before it became a reality, when she served as a community activist.

In late 1969, El Rio's Board of Directors sent a letter to Elenez offering her a job as a receptionist. This occurred during the first round of hiring of clinic personnel. When she got the offer, she responded that she had vision problems and turned down the job. Elenez had a serious visual impairment and arthritis. In the early days of El Rio, the community sought new ways to handle old problems such as hiring people with physical disabilities. This resulted in the development of personnel policies which provided wider opportunities. Before the national disability act finally passed, El Rio hired some people with disabilities. After graduating from Pima Community College, Elenez remained unemployed six months until Julia Soto recommended that Elenez again be offered a job. After reconsidering, Elenez faced a job interviewed by a community board who consisted of members from the Model Cities Program. The interview process seemed unnecessary to Elenez as she knew many of the board members and expected to be hired.

Elenez, hired on October 1, 1971, went to work at El Rio's first site, a converted juvenile disciplinary center commonly known as "Mother Higgins." At work, Elenez first read then interpreted physicians' directions and then moved the process forward. Instead of working as a receptionist, she functioned as the Suite Secretary. She never received training and had a difficult time at first, but still remembered that first year as the best year because, as she recalled,

"We were small, the team was closely knit and Friday mornings we got together to discuss patients with problems and how to follow through."

For all three graduates of the Model Cities Program, Elenez, Tovar and Soto, the new health facility and the community it served remained of central importance.

Years later, in a 1994 interview, Abrams was asked,

"How do you think the presence of the clinic has affected the health or the health care of the people in that area?"

Abrams responded,

"That's a good question. Just this morning I was looking at the application we wrote out in 1969 to send to the federal government asking for the money for it. And in that application, I had personally done a study of infant mortality rates in the area, venereal disease rates--this was long before AIDS was known--but we looked at VD, at TB, at communicable diseases like measles and others, and so on. And we found all the rates of those diseases were much higher in that area than they were in the rest of Tucson. I did a 'census track study.' We found school absences, of children, for health reasons, were excessive. We found fewer doctors per population in that area. Of the doctors who were in the area, they were at a much older age level than doctors in the rest of the community, and so forth. What had happened was, most of the doctors in the community had moved to the East Side where the more affluent and middle-class people were, and there were very few doctors left in the old neighborhood. Those were the problems. I have since tried to interest someone to study the situation again, but I haven't succeeded. I can guess that things are better, but I don't have the data on it.

Oh, we also studied the environmental problems. For example, in those days, a large percentage of the houses in the neighborhood had no running water. Many had no electricity. So you can imagine they had no way of refrigerating the milk and other foods. They had outside privies. A lot of that has been corrected, but I wouldn't be surprised if some of that still exists in the neighborhood. The Model Cities Program, I know, built new privies. Whether they ultimately put in running water and modern toilets, I'm not sure. But I suppose a lot of them have improved."

As the Model Cities Program got under way with federal funds and support from the University of Arizona, some immediate beneficial outcomes, while not documented, did become evident. A once lethargic area of Tucson transformed itself into a vibrant, exciting, innovative community. Dusty streets became paved. Darkened areas became lit. Shacks gave way to well-constructed homes. Privies went inside with plumbing. Pregnant women and their new born infants who had no medical support now had both support and some basic nutrition. Latch key kids became students at Head Start and in after school programs. Children who had never seen a dentist saw one at El Rio. Children who went through school hungry now had school lunches. People who never had physicals now had them. Youth with bleak futures began to have hope for careers. People without hope of jobs received job training. Senior citizens with no hope, found hope in day care centers which focused on their needs. Where there had been no accessibility to health care facilities, El Rio provided a broad spectrum of quality care. The once seemingly apathetic community became alive and a very interesting and desirable place to live with dignity and pride. In October of 1970, the clinic opened and El Rio became the first, and perhaps only, health care facility in the state controlled by the people it served. At a time when people throughout the city and county looked for a sense of community, the people in the Model Cities area of Tucson had found one.

When President Johnson declared war on poverty in 1964, the rate of poverty in the United States was 19%. By 1973, the rate dropped to about 11% where it stayed for the rest of the decade. By 1982, it grew again in response to cuts by the Reagan Administration.*

*Source: U.S. Bureau of Census, Current Populations Reports, p. 60.

Philosophy of the Clinic

In a letter to the Board of Directors dated August 4, 1980, Abrams laid out the initial driving philosophies of El Rio: (1) health care should be a right for all individuals, (2) employees should be trained from the neighborhood for health care positions, (3) a community board to be elected by registered patients should govern the clinic, and (4) employees as patients should have input to the board by voting for their representatives to the board. Many, if not most, of the early employees had strong commitments to these philosophies.

As the national policy changed from supporting community health centers to supporting Health Maintenance Organizations (HMO), the ideal that "health care should be a right" would be severely tested at El Rio. By 1977, the clinic began soliciting HMO patient. The first HMO plan at El Rio sought to bring in patients that enjoyed Medicare coverage. This beginning later expanded to include business groups. Decisions to close enrollment to community people ran concurrent with the growth of the HMO. These practical changes reflected the philosophical changes at the national level and they caused serious problems for El Rio employees.

Although El Rio brought some people into employment from outside the contiguous community, it always maintained a significant core of people who came from neighborhoods surrounding El Rio. To many, the term "community" meant Mexican-American or minority but a legitimate part of the community also included elderly "Anglo" residents. Additionally, some minority employees lived significantly outside the Model Cities area. Still, the concept that employees should be trained from the neighborhood for the health care positions became possibly the most successfully met ideal. Many of those people who found employment at El Rio received specialized training that went a long way in producing valued service.

Initially, a community board governed the clinic. The seeds for ending that arrangement came when an arrogant activist saw the board as a vehicle for personal power. Because of events starting in 1979 and also changes in national policy, the ability of patients to elect people to serve on the board eroded and ultimately resulted in the disenfranchisement of the community. Formal input to the board ended first while informal input lasted only a few years longer.

Although many of the original philosophies erode, as time past, due to both internal and external factions, the ideal of maintaining employees from the community mainly succeeded and some of that success came from protection provided by the union.

Looking back at the initial philosophies at El Rio, Gloria Gonzales, a well educated Yaqui Native American, employed in 1976 and later a union activist, recalled many workers enjoyed shared values about the community and about the direction of the clinic. She believed that the initial philosophies prevailed until strife arose between the board and the employees.

The Community Board

Because of the federal government requirement that communities control the policy of the neighborhood health centers, many people from the community needed to be on the Board of Directors. At first, people did not wish to serve because the community grappled with suspicions about the motives of the people from the university.

The federal funding agency required both community and professional direction from this policy making board. So in addition to the people who represented their specific areas, the federal government also required a lessor number of people, proficient with specialized technical skills, to also be apart of the board.

With the help of the Model Cities Program, it was decided that the El Rio community board be primarily made up of representatives from model cities and from barrios within the neighborhood. The first Board of Directors, made up of twenty-one persons, had sixteen elected to represent the barrios and model cities area together with five professionals from the whole community.

The first board was put together with the aid of Bill Maytorena, the first community liaison worker, who in the early days could be seen bicycling through the area. The well-liked Maytorena later became El Rio's first supervisor of El Rio's Social Service Department. When employees were hired from outside the community, Maytorena took those new employees on bicycle tours to acquaint them with the neighborhood.

The full board attended monthly meetings in addition to frequent meetings of standing committees: Executive, Budget, Quality Assurance, Finance, Personnel, Grievance and By-laws. In time the HMO also became a standing committee. The composition and responsibilities of the board and its committees were detailed in the corporation by-laws. The board hired the Executive Director of the clinic, who then functioned ideally as a liaison between the board and the clinic employees.

The community people elected to positions on the board served a two-year term. Each year during the early years of El Rio, community wide elections for half of the board members were held. While few people bothered voting, most saw the elections as an essential ingredient for a true community board.

The issue of who controlled the clinic arose very early. About 1971, the question arose over whether the university, the board or the administrative staff controlled policy and operational decisions. This issue festered over the years until 1974 when the clinic became independent of the university. During the early years of the Jose Maltos' Administration, after the clinic separated from the university, the issue of control did not appear to be a big problem. But later, the issue reemerges with a vengeance when conflict arose which involved the administration, Board of Directors and employees.

In the early 1970's, Jessie Reece, the secretary to the new Board of Directors, believed strongly in the mission of El Rio as a place to train local people for the work of the clinic. Her job as secretary now required that she be at all the board meetings, including the committee meetings. Heated arguments often occurred at these board meetings.

One common area for argument concerned who should be hired. Every new El Rio employee, in the early days of the clinic, had to be interviewed by the board's Personnel Committee. Professional people who came from outside the community had to be approved by the board. Generally, however, an applicant indicated what unit of Model Cities or barrio he or she came from and then that applicant might receive advocacy from the board member representing that area. But this could and did produce conflict between competing areas.

Conflicts also arose over other issues. For example, any new study also had to be approved by the board and this could produce powerful emotions. One of the early studies to seek such approval involved lead poisoning in children. The board had concerns about possible experimentation using their children, and so they did not allow the study to go forward.

A grievance procedure had been set up to deal with employee problems. This procedure began with the initial administrative handling of the problem and when that failed the problem went on to Personnel Committee of the board. Some employees enjoyed a sense of protection from this grievance procedure.

Alicia Tovar explained it this way. She thought the board had strong ties to the community in the early days, while the clinic stayed at the old Mother Higgins home. "All you had to do was put a bug in a board members ears and it (a grievance) was heard." Tovar told of taking a problem to them when a staff supervisor made inappropriate remarks. She recalled that the board made decisions on internal conflicts because some board members thought they did not hearing everything from the administrators.

In contrast, Reece saw problems with the board usurping administrative decisions. She believed that about the year 1977, just before Baldenegro served as the board president, the board became too involved in the administration of the clinic, "(even) to the point of contacting the Personnel Department and indicating the department should hire someone." After one such incident, Reece sought advice from Soto and Soto said that board members were not allowed to give directions to employees.

The powerful concept of the community board had both flaws and strengths.

Training People for New Jobs

El Rio began training unskilled women who lived in the surrounding neighborhoods to do a modified type of social work and nursing. These women visited homes where babies had just been born or where significant health problems existed. People from the community also trained for positions as family health workers (a new concept), suite secretaries, medical records clerks, lab technicians, x-ray assistants and pharmacy assistants. Many early employees later went on to continue their education and became certified nursing assistants, licensed practical nurses, registered nurses, dentists and physicians.

Employees, through their El Rio experiences, climbed up the career ladder. Registered nurses trained as family nurse practitioners within one year. The first seven family nurse practitioners in Arizona came out of the El Rio program. After a few years, the University of Arizona College of Nursing took over the program and provided certification. Initially, lab technicians trained at El Rio. These people also came from the neighborhood.

Tovar, one of El Rio's first employees, was hired about June of 1970 as a clerk typist shortly after she graduating from high school. Although not very good at clerical work, she had many skills needed at El Rio. Tovar showed a strong sense of convictions and rejected narrow ideological thinking; she was a risk taker despite some personal loss, out going and friendly, very perceptive and open to new ideas, a fast learner who quickly understood how to apply her knowledge, and sensitive to people's needs and tolerant of differences. She also displayed strong communication skills both in Spanish and English, good leadership skills and a strong sense of community, and a vision of social justice and fair treatment for all. The El Rio experience allowed Tovar to develop her innate talents.

The concept of education remained an important goal for El Rio employees. When the union came to El Rio, contract language both enabled and protected employees rights to obtain and maintain their education.

Because of these increased educational opportunities, the community gained additionally from new economic benefits. Those increased benefits had a multiplying effect. As individual workers acquired more income their families obtained greater resources. As the families derived greater resources the community flourished. With increased improvements to the community fewer people wanted to relocate. This was dramatically evident in old Pasqua, the Yaqui community north of the clinic. Before El Rio, the people in this Yaqui village lived in shacks made of corrugated metal and cardboard. No street lights or even real streets existed. Sanitary facilities were absent. All this changed during the time Yaquis worked at El Rio. Today these people live in modest homes with indoor bathroom facilities. The streets are paved and the community has night lights. To a lesser degree, these changes also improved other neighborhoods.

National Health Service Corp.

Under a federally funded program, newly graduated physicians and other highly trained and qualified health care professionals returned a year of service for each year they received a government loan. The service, delivered in a medically disadvantaged area, usually involved an urban area with a large minority population or in a rural setting. For a clinic like El Rio that meant they could have access to young newly-trained physicians, nurse practitioners and others without having to pay high wages for extensively educated employees.

Professionals under the National Health Service Corps (NHSC) enjoyed a degree of independence from the administration where they worked. In 1979 and 1980, El Rio had NHSC professionals working at El Rio. The NHSC professionals at El Rio were five physicians, two nurse practitioners, two pharmacists and one dentist about that time. While El Rio could not fire

NHSC employees, it could opt to discontinue the relationship. Because of the financial savings involved, it seemed unlikely an El Rio administration would choose to discontinue NHSC employee's services except in a most egregious situation. But this would happen at El Rio.

The NHSC was established about the time of the Johnson Administration. Later, during the Nixon and Reagan Administrations, funds for the program were cut and the program eventually terminated.

The Team Approach

Not only was El Rio unique in its use of community involvement, but also in its conception of the delivery of health care. One innovation at El Rio involved the idea of the "mini-team." A mini-team integrated the work of a physician, nurse practitioner, and community family health worker. The full team included clinic nursing staff, a nutritionist and a social worker. The community family health workers functioned as the liaisons between the patient and the health professional. Part of their duties included attempting to help patients get access to the system and help health professionals understand the patient's environment. Essentially, they held responsible for bridging barriers caused by cultural, economic and social differences.

Inherent in this philosophy was the concept that the family health workers had, and provided, expertise in an area in which health professionals would generally be lacking. This radical new concept had a lot of problems that needed to be overcome but also some great benefits gained acceptance.

The family health workers had a dual role. The social concept was also tied to providing some basic nursing services. So family health workers trained to take vital signs; temperature, weight, and blood pressure. They also assisted in patient examinations and in certain medical procedures. These workers also provided interpreting skills which often involved medical terminology. Because of their dual roles, the question of who should supervise their work arose: social service? nurses? physicians? Later, having two types of family health workers solved this problem. One specialized in work with the community through social services and the other specialized in health care through their work with the health providers.

In the traditional health care setting, at the time, the physician headed the team. At El Rio, proceeded against the current traditional norms. In a team approach, in medical matters the physician still maintained recognition as the top authority. However, in some areas of work the nurse practitioner, the registered nurse or the family health worker theoretically had leadership responsibilities. For example, the nurse practitioners had the authority when it came to prioritizing the patient visits and general scheduling while the family health worker, in theory, assumed responsibility as the chief advocate for the patient as it related to the patient's social setting.

Mary Lou Gonzales felt attracted to the new concept. She had just completed the nursing program at the University of Arizona and had never dreamed of a job like the one being developed at El Rio. Registered nurses could take on some responsibilities traditionally held by physicians, such as performing physical exams, diagnosing and treating some illnesses as well as performing some mental health counseling and health education. The physicians' role shifted to consultant and colleagues who handled the more complex problems. Many beneficial outcomes arose from this approach and chief among them were: lower health care costs, more efficient use of resources, and increased access to care for more people through the better utilization of staff time. Additionally, family nurse practitioners could give patients longer time with a qualified health professional. Prior to El Rio, the physician saw the nurses as their hand maidens. The concept of "Team" changed that concept.

The team approach meant that El Rio physicians could call upon the services of nutritionists, health educators, pharmacists, dentists and social services. At that time, the idea of the team approach displayed a new concept. Furthermore, all those services were to be provided at one site and that site was to be located in a medically underserved community. At the time the clinic opened, Hispanic physicians were difficult to find and employ. Dr. Mary Ann Sullivan, hired shortly before the clinic opened, served as one of the earliest team physicians. Virginia Bishop, among the first family nurse practitioners in Arizona, served on Sullivan's team. Bishop remembered Sullivan as, "sensitive, knowledgeable and caring".

Dr. Helen Johnson, a pediatrician, another physician hired about that time together with Sullivan, helped in the teaching of the registered nurses who eventually became nurse practitioners. Among the other physicians hired early at El Rio were Irv Neiman, Peter Mott, Dan Levinson and Fred Hirsh. Neiman worked hard at bringing in the first Health Maintenance Organization, a plan for Medicare patients. Still shortages in obtaining physicians persisted.

Because of the national policy in the early 1970's to expand health care coverage to communities which had inadequate or no access to health care services, the concept of the nurse practitioners developed. The shortage of physicians which prevailed at this time gave rise to the situation of very few physicians being willing to work with minority or poor people on the west side of Tucson. So shortages of physicians grew greater in the model cities area.

In the beginning, nurse practitioners at El Rio had several roles that played out at the same time. The nurse practitioners in training also delivered traditional nursing services. Because new new roles emerged, the concept of the nurse practitioner needed to be established. Within the nursing profession the discussion built governing where lines should be drawn and who should have responsibility for what. The question of where lines should be drawn was also seriously discussed among the nurse practitioners and physicians. Even with great jurisdictional concerns, an immense positive expectation persisted about what nurse practitioner could accomplish.

The Magnificent Seven

Nurse practitioners, trained beyond the skills of registered nurses, offered some services traditionally provided by medical doctors. Among their duties existed routine physical exams, screening, management of minor illnesses, and routine maintenance of chronic illnesses. The nurse practitioners also provided patient health education and counseling.

This turn out to be a more efficient and effective way of treating many patients even when adequate physicians became available.

While getting their education to be nurse practitioners, i.e. studying, reviewing and learning to do the physical assessment skills, Mary Lou Gonzales recalled they also had to be the team leaders of the mini-teams, make home evaluations, teach and supervise the staff, and perform traditional nursing functions like giving treatments and injections.. Gonzales remembered working hard and playing hard. Gonzales enjoyed the challenge.

The clinic, in those early days, was divided into mini-teams. Each mini-team had a community worker, a physician and a nurse practitioner. The nurse practitioner, as the team leader, had responsibility for coordinating the care of the patients with the family health worker and the physician.

The team theoretically worked with the neighborhood residents to help them access the clinic for their health care. The mini-team also had more support from the nutritionist, social service staff and other health care agencies in town.

Gonzales told of an example of how problems became solved in the early days. She remembered working with a family whose son, diagnosed with juvenile diabetes, was not growing properly. The physician specialist at the Pima County Hospital notified us at El Rio. The nutritionist and Gonzales made a home visit to help the family plan the boy's meals. Gonzales also enabled the mother to learn how to give her son insulin injections. It was a successful cooperative effort.

The first group of seven nurse practitioners were Virginia Bishop, Mary Kay Dempsey, Mary Lou Gonzales, Barbara Hanley, Trudy Leonard, Shirley Tetrault, and Zora Zemsky. They became known as Family Nurse Practitioners or FNP. They were first trained and then questioned about appropriate training or education for future nurse practitioners. The seven recommended that nurse practitioners receive formal class training first and later practical experience. As an extension of their recommendation, they helped set up the Nurse Practitioner Program at the University of Arizona College of Nursing.

Additionally, this first group of seven were instrumental in pioneering the Arizona State Nurse Practice Act which allowed nurse practitioners to practice legally in the state of Arizona. These nurse practitioners met with other nurse practitioners in all parts of the state, but mainly in Tucson, Flagstaff and Phoenix, to establish perimeters of practice and to plan strategically so that they could secure support from the state Board of Nursing, State Nurses Association, and the University of Arizona. The seven nurses helped plan the curriculum for the next group of nurse practitioner students and they helped define the roles for the family nurse practitioners. They also wrote state regulations governing nurse practitioners and then got a state legislator, Peter Goudinoff, to introduce the bill. It took many years and lots of work but they accomplished what they had set out to do. Arizona ranked among the first states to establish legislation for this type of practice.

In due time, this group of seven stood among first nurse practitioners in Arizona to get privileges which allowed them to write some prescriptions. Arizona also stood as one of the first states to allow nurse practitioners prescription privileges.

Eventually, by 1974, the Arizona Board of Nursing developed tests for certification as nurse practitioners. The first exams in Arizona were given at the University of Arizona and in the second group that took those exams were the original seven from El Rio. When they graduated, they called themselves "the magnificent seven".

The magnificent seven were excited to be involved in developing a new nursing role as well as a new health care delivery system. For Mary Lou Gonzales, this was the first job where nurses were actually treated as colleagues.

The El Rio nurse practitioners believed "in our strengths" according to Virginia Bishop who had been hired in the later part of 1970. Bishop remembered that they were very tightly knit, which she believed made them strong.

Virginia Bishop, hired initially as a registered nurse, provided services through a team approach which sought nurses from the barrios. Bishop's team included two physicians-one in pediatrics and the other an internist, two other registered nurses, a nursing supervisor and a family health worker. The other two registered nurses on Bishop's team also eventually became nurse practitioners.

Before coming to El Rio, from about 1962 to 1968, Bishop had worked as a registered nurse at Pima County Hospital. She left employment there because she wanted to coordinate her work with her family needs. Bishop learned about a new type of nurse which would come to be known as nurse practitioners. She also learned about a new kind of health center which would be called the El Rio Santa Cruz Neighborhood Health Center. Bishop liked what she heard. She also appreciated the concept of being able to work more amenable hours. So, for Bishop, the way of providing care, the place of providing care and the working hours all projected positive features of this new model cities program.

By September of 1970, Bishop was the last to be hired among the magnificent seven. While working with the El Rio team, Bishop also trained as a family nurse practitioner. She had to attend formal classes. At first she spent about three or four hours per day in class. Later, more clinic time superceded the reduced class time. Everything was new. Even the rules were different and new. They had to establish rules for everyday operations.

When the clinic opened on October 16, 1970, Bishop remembered that the staff lacked readiness for the opening. The clinic opened because the community board said that it had to be opened. The clinic closed the same day and eventually reopened in early November.

"We were being controlled by a lay group that, I thought, did not know what they were doing. It was like a rocky boat with a few leaks."

This proved a nerve racking and frustrating experience for Bishop.

The Arizona State Bachelor of Nursing (ASBON) developed tests for certification as a nurse practitioner. Bishop, Mary Lou Gonzales and the other five registered El Rio nurses took their tests at the University of Arizona.

As nurse practitioners, the seven functioned as supervisors of all people assigned to them, as educators and as monitors of patients with stable diabetes and hypertension. Time was set aside for education as they shared responsible for teaching simple nursing skills such as (1) child development, (2) immunization, and (3) family interaction. Nurse practitioners also learned how to manage urinary tract infections. Eventually, nurse practitioners wanted to deal with other problems.

Still the nurse practitioners had access to physicians if the patients problems became too complicated. Bishop remembered that she could get doctors involved and this whole process helped her to increase her understanding of the problems.

At times Bishop worked triage. The triage is what most places today might call an urgent care center: a place where people could be seen in one day, not in an emergency room setting. Bishop liked triage because it always seemed interesting. While health maintenance accomplished impressive results, it could get boring.

Bishop served four months as the Nursing Director. This involved lots of desk work and this she did not like. There were frequent meetings and the Nursing Director got dumped on often. The board meetings could get mean at times. As Nursing Director, Bishop had to deal with the Board of Directors. From this experience Bishop saw lots of problems involving the budget and personnel.

In the early 1980's, after many of the original core of physicians had left El Rio, attempts to get rid of the nurse practitioners started and that continued to the present. It became common to have confrontations with some physicians.

Board-Staff-Patient Relationships

Cultural and social barriers needed to be bridged and it was often very difficult if not impossible to accomplish. At El Rio those differences went beyond just "Anglos" and "Mexican-Americans." Real cultural bridges needed to be built among all the different ethnic groups and at El Rio this included Native Americans, African-Americans, Jewish-Americans and Anglos among others. Additionally diversities existed within ethnic groups. Educational background provided other significant barriers that could divide employees. Most employees wanted to build those bridges and work cooperatively. However, when conflict arose the differences between people were heightened by some as a device to obtain their goals.

One example of the potential dividing factors involved the use of language. Some Mexican-Americans felt disadvantaged if the use of English predominated. In contrast, African-Americans, Anglos and others felt disadvantaged if bilingual skills predominated. The Board of Directors hired Pat Morris in 1973 as a Dental Assistant. In the early days, the dental clinic only serviced children and El Rio employees. It later expanded to include adults. Morris remembered the conflict over whether or not to hire only bilingual people. This emerged as an intimidating problem in the early days. If they only hired bilingual people, then most African-Americans would be ineligible to be employed. If African-Americans were not hired, this would be an inhibiting factor facing African-American patients.

Differences in education and income also prevailed. Many employees did not want those differences to act as barriers between people but some barriers remained too powerful to overcome. If an employee gave a party, inevitably most employees did not cross social lines even when those affairs were introduced as being open to all. An exception occurred when employees later enjoyed a major celebration of the first uniting of employees which ultimately led to the one union. At the end of October in 1981, a huge joyous party at the home of Barbara Warren, a highly respected El Rio physician, surmounted differences when employees enjoyed their anniversary celebration. Employees from very diverse ethnic, social and educational backgrounds attended the party.

Mary Lou Gonzales remembered that parties went back to the earliest days of El Rio. They generally started with happy hours on Friday evenings. Since many new employees from all over the country came to El Rio, these parties served to get employees acquainted. The informal gatherings usually involved snacks, beer, wine and soda. In addition to the entry level, professional, medical and administrative people who attended - model cities community leaders and the University of Arizona College of Medicine staff also joined these functions. Although the happy hours were informal, a lot of policy and administrative decisions were discussed and later brought to the administration. At times these suggestions were accepted because in the early days, employee input into the policies of the clinic did not appear as a threat. But that would change. Many close knit personal and professional relationships developed and continued for many years. In the early seventies, there existed a sense of optimism, community, and of working together towards common goals which included improving and developing a new health care system. The people of El Rio believed it could be done.

Other celebrations included birthdays, Christmas, weddings, baby showers, house warmings, anniversaries, bridal showers, and going-away parties. Potlucks were everybody's favorites. People prided themselves on their cooking. Green corn tamales when in season, enchiladas, desserts, refried beans, tacos, birria, and many popular dishes were on the menu. Mary Lou Gonzales recalled that

"...these parties were fun, developed cohesiveness, unity and gave us a sense of family. Many employees saw themselves as a part of the El Rio family. Not only did we share in joyous events, we comforted ourselves in the losses of our loved ones, friends or family, by attending funerals and wakes. If there was a family emergency, such as loss of job or fire or any other disaster, the employees would contribute financially or hold fund raisers to help the cause."

Everyone was encouraged to participate. Most did to some extent. Much of the sense of family continued into the 1990's.

Once the clinic opened, in the very earliest days, Gonzales recalled going to "de-briefing sessions" at nearby hotels with front line staff. These sessions had no expressed purpose except to eat a meal and have a libation. If there was music, they would dance and sing. If they had a very hard night's work, they would commiserate with each other about their troubles. When conflict came, employees and physicians along with some patients had already developed strong bonds.

Tovar enjoyed a familiarity with some of the members of the Board of Directors. At one time she worked with the sister of one of the members of the board. Tovar also dated the board president. She also knew other board members. So very early in the history of El Rio, Tovar felt comfortable communicating with members of the board.

Many of Tovar's neighbors also worked at El Rio. While the clinic stayed still at the first location, Tovar understood that the board had a grievance process that was supposed to make decisions on internal conflicts using a certain established process. Tovar remembered those early days as a time when the board valued strong ties to the community.

In the late 1970's, an incident occurred that contributed to later conflicts. Tovar worked with a physician who had a radical outlook. This physician frequently butted heads with the Medical Director. Tovar saw many of this physician's requests denied by the Medical Director. On one occasion, the physician planned to take a few days off and Tovar was asked to handle schedule changes. No formal procedures that had to be followed, existed at this time, so she just made the necessary schedule changes. At this same time, her nursing team leader was married to a man who worked with the border patrols. Tovar heard this team leader refer to "wet backs", a racist term that Tovar abhorred. The relationship between the team leader and Tovar became strained. When the physician's day off came, the team leader fumed about the change in schedule and let Tovar know her anger. Jose Maltos, the clinic's Executive Director, supported the team leader and suspended Tovar without pay. By this time the grievance process had grown long and drawn out so Tovar hired an attorney to get her job back. Tovar went back to work to the hugs and cheers of many of her co-workers.

But not all employees supported Tovar. Alice Gallardo, a vivacious, middle-aged woman, began work at El Rio shortly after El Rio moved to a new facility on West Congress Street. Hired as a temporary family health worker to replace a woman on maternity leave, Gallardo had not planned to work permanently. But after three months, the physician she worked with encouraged her to stay on. Gallardo needed very little encouragement as she found El Rio "...a neat place to work. Everyday I got up glad to go to work."

Gallardo thought Tovar held grudges against all administrators and did not show overt concerned for the patients. But, she believed that the problem between Tovar and Maltos "seemed more personal" so Gallardo found no interested in that conflict. Still, she felt that Maltos should not have asked Tovar to "squeal on the physician" and also Maltos should not have threatened to fire Tovar. Gallardo found it difficult to understand Tovar.

Gallardo believed that "patient care should be the primary concern." "People's attitudes got to me," she remembered. "Patients would come back from the front desk unhappy and angry." One day as a new employee, Gallardo stopped by the front desk and asked to become an El Rio patient. She experienced rude treatment. This motivated her to work for the improvement of attitudes towards the patients. While Gallardo believed that the medical staff "was good", she thought that some other employees did not care for the patients.

Gallardo recalled an incident when she worked with one of the physicians. Some employees displayed meanness to one patient known as a frequent pest. The physician arranged with Gallardo so that when the woman came in, he saw her as soon as possible, but for only for a moment. Other employees complained and again this led Gallardo to believe that those employees did not care for the patients.

Barbara Warren's employment at El Rio as a staff physician began in 1978. In her first impression, she appraised El Rio as being community oriented with a well organized clinical delivery system. This she liked. Her arrival at the clinic occurred at the tail end of Tovars conflict with the administrator, Jose Maltos. Warren stayed out of the early conflict, but she later develop warm feelings towards Tovar.

Dolores Elenez, among the first hired, remembered the initial holistic and aggressive approach to community problems. In the early days, El Rio staff and students from the University of Arizona Newman Center went to patients' homes and helped repair those homes. There existed an understanding, at that time, that the environment one lived in effected one's health so that a house without adequate sanitation facilities worked against good health.

Elenez believed patients received special treatment at the clinic during the early day. One incident she remembered involved the treatment given to a particular patient. Mr. X had severe heart problems. The staff had been alerted by Dr. Sullivan to respond aggressively if Mr. X phoned. Subsequently, Mr. X called to report breathing problems. He received instructions to come into El Rio and when he arrived the staff was prepared. Elenez believed that approach basically saved his life.

Neighbors, friends and family of Elenez often utilized the clinic facilities. Additionally three family members, an uncle and two cousins, had employment at El Rio. So Elenez had multi-dimensional ties to El Rio.

Herself disabled, Elenez had a concern for the patients which went beyond her normal working chores. She saw that many patients were unable to afford the expensive medication that they required. Ethel Larsen, the accountant who had been hired the summer of 1976, remembered that some patients were confronted with the dilemma; whether to use their very limited money for food or for medications. For many patients, this had been an on going problem. Elenez responded to the problem by setting up a "Pharmacy Assistance Program" where employees could contribute their own monies to a fund to be used to pay for medication for patients. Although this fund never lasted beyond the first few months of each year, the employees continued to maintain it.

Another Yaqui, Gloria Gonzales, believed that initially El Rio enjoyed good relations with the community.

"We were all related in some way. I had long term relations with patients prior to being a provider. Also, I thought it very important that minority people saw professionals and providers who were also minorities. Even the people who were not minority made the effort to speak the language."

Pat Morris remembered that her first impression of El Rio was of a good facility for low income people. Her first encounter as a patient came in the early 1970's. Morris used to take her son to the clinic. She had been at the county hospital and compared to the hospital, El Rio looked very good. Morris, who had began her employment at El Rio by working in the dental clinic, stayed there throughout the time of her employment which spanned more than twenty years. Morris recalled that El Rio was "always opening and closing" services to the community. Although problems with registration existed, she believed that, in general, employees were sensitive to patients' needs.

Julia Soto, an outgoing, vocal Mexican-American born in 1930, served on El Rio's first Board of Directors. She also trained as one of the state's first patient advocates. At the twenty year celebration, Soto recalled the ground work that she and others participated in before there could be a clinic. In newspaper coverage of the event, Soto is quoted as saying

"We went to homes to visit people too sick to come in. We didn't wait for (patients with) health needs to come to us."

Soto eventually became an El Rio employee and worked as a full time Director of Community Relations. When Soto came to El Rio she was the mother of seven children.

An HMO Comes to El Rio

While the clinic searched for an ideal world in health care, one where patients and physicians worked together in partnership toward common goals, another potentially more insidious model began to rear its head. The HMO began making its debut in the world of health care and on the stage at El Rio. El Rio received Certification on July 1, 1975 to operate as an HMO. Another year past before the first plan became actuated.

People were enrolled in the HMO by groups. HMOs market their product, health care services, to mostly employer groups or government funded groups. People covered by Medicare heard that they would not have to pay more than a slight fee for hospitalization or pharmaceuticals. This often looked attractive to people on limited incomes. The down side, often not appreciated, resulted in limited or even reduced patients' access to hospitals and pharmaceuticals in accordance with guidelines that were not always appropriate to the illness.

At El Rio, the first group to have HMO options were people covered by Medicare. The introduction of the HMO at El Rio posed a serious problem for the NHSC physicians who had contractual obligations to provide medical skills to the under-served populations. To worsen the problem, the same time that HMO patients began to use the services at El Rio, indigent patients for whom El Rio was established were being disenrolled, kicked out.

Some of the board members became threatened when NHSC physicians began to state their legitimate concerns. It would be interpreted as physicians wanting to take control over the community board. As the El Rio physicians expressed their reservations and concerns about this new model of health care, the HMO seemed innocuous enough to Larsen.

Ethel Larsen, who had recently finished studies at the University of Arizona in anthropology and Judaic studies, but who also had experience and a few classes in accounting, began her El Rio employment as a junior accountant in 1977. She felt excited about the opportunity to work in a culturally diverse community. Shortly after coming to El Rio, Larsen set up the accounts for the first El Rio HMO patients, a Medicare supplement plan. Patients who had Medicare coverage could pay an additional $13.80 per month to El Rio's HMO and then they could be covered for hospitalizations, pharmacy and other benefits. In a relatively short time, the Yaquis came under an HMO program and for them, this program signified a great improvement over what had been.

The Yaqui HMO contract proved a great thing for the people, according to Gloria Gonzales.

"Now the patients are very well educated in their health needs, but at first they were very frightened. We succeeded in educating them and that is what you want."

In time, however, additional problems surrounding the HMO program materialized. A question that persisted for some employees: were the HMO programs subsidizing the cost of health care for the notch population or was it the other way round? Other questions also arose. Could NHSC physicians work in a for-profit setting when they had an obligation to service the under-served and the poverty or near poverty populations? What happens when registration was denied to the service area but opened to HMO groups outside the area? These problems and other similar problems festered and become an undercurrent in the conflicts that later arose.

One of the NHSC physicians who subsequently had serious problems with the HMO when she saw her patients being disenrolled was Dr. Ava Wolfe. She began working at El Rio in the late 1970's. Wolfe believed in a multi-disciplinary approach to health care delivery within a community-controlled setting, in essence El Rio. Within a very short time, Wolfe became a well- respected and well-loved pediatrician at El Rio. But she also became known as a "whistle-blower," someone willing to point out inappropriate administrative or board behavior.

Wolfe's co-workers remembered her as being the only physician who came to work on her day off to update records. Reece thought Wolfe was very competent and Warren saw Wolfe as an outspoken advocate for her patients and also as an excellent, caring physician. In a questionnaire, two of Wolfe's subordinates were on record. On one questionnaire, in response to "Greatest strength" the respondent answered "unbridled enthusiasm," while the other wrote, "very through, very concerned about her patients - will go to great lengths to see that her patients are receiving adequate treatment." Wolfe probably enjoyed universal appreciation by those around her. This had important implications in the later conflict at El Rio.

Mary Lou Gonzales remembered one problem that appeared as early as 1971; the issue of registration closure to community people. El Rio had too many patients with too few providers within inadequate space causing reoccurring problems. The difference between 1971 and years later could be seen by how the administration dealt with these problems. In the early days they were brought before the full staff and discussed and possible solutions explored. So the staff in the early years wanted registration closed. That changed after the HMO came to El Rio.

The El Rio Facilities

The first site for El Rio, the old "Mother Higgins Home", was located just west of the major freeway known as I-10. El Rio leased the building from Pima County for $1 a year. The building had been the county jail for juveniles but remained unoccupied when Abrams came along because Pima County had recently established a new jail, with juvenile detention facilities, on Ajo Way. Mother Higgins Home had bars on the windows and eighteen rooms with urinals. They measured nine by ten in dimension and each room had double bunks for the kids. With the aid of federal money, $3 million for 5 years, and a grant of $50,000 from Pima County, the facility was remodeled.

Air conditioning and hot water were brought in, the bars were removed and the rooms were painted. Many employees contributed their personal time to help and paint the facility. The employees felt that the clinic belonged to them. All the rooms received painted pastel yellow and blue paint. The jail cells became attractive medical examining rooms and a court room became a board conference room. On October 15, 1970, El Rio officially opened its doors. From the start, their 85 member staff treated more than 3,500 patients.

In 1971 a $124,000 federal grant awarded to El Rio provided funds for a dental clinic. The dental program was added two years after the El Rio's doors opened. The first of six trailers, added before receiving federal funds, housed the dental clinic.

After its initial start, El Rio applied for and received federal money under the Hill-Burton Act. This Act provided funds for capital expenditures, buildings and expensive equipment in medically under-served areas. To receive such funds, free services, up to the amount of the Hill Burton Award, were to be given to the poor. The Hill Burton funds went toward the building of a new clinic at 839 West Congress Street. The clinic moved to its present site on West Congress in July of 1976.

While Dr. Irv Neiman, the Medical Director at the time, played a major role in bringing about the new clinic, Jose Maltos was El Rio's Executive Director. Maltos enthusiastically particiapted in the planning, building and moving into the new facilities. Pat Patton, Maltos' loyal secretary, believed that Maltos experienced both high and low points in his life while at El Rio. The role that Maltos played in bringing about the construction of the current clinic was perhaps his high point. Later events that led towards his leaving El Rio were probably the low point.

Mary Lou Gonzales recalled that when the staff moved to 839 W. Congress, the traditional stark white and dull green colors seen in most clinics and hospitals gave way to lively, bright colors. She had heard that Maltos chose brilliant colors for the walls, medical suites, waiting rooms, examining rooms and the clinic lobby. Brilliant oranges, warm greens, bright yellows, soft browns and vivid purples greeted her first view of the clinic. The nursing staff co-ordinated the colors of their uniforms to their suites. The colorful and attractive working environment provided a cheerful place for patients.

Lush green leafy plants in the lobby and entrances to the suites set-off the roomy and bright walls. During holidays, different departments decorated their work areas and competed for prizes. At Halloween, different areas could have themes that ranged from Frankenstein's lab to a MASH Unit, and employees in these areas followed the motifs in their costumes. One year an x-ray technician inadvertently scared some children with her witch's costume and wicked laugh. A lot of creativity, enthusiasm, cooperation and fun went into these activities and decorations.

The doors of El Rio's new facilities opened on July 5, 1977. At that time, Rosemary Diaz headed the Board of Directors and Salomon Baldenegro had a seat on that board. Elenez remembered the move from the Mother Higgins site to the new location as a special time. She felt that Maltos had kept the staff well informed about the progress of the building of the new site. He had been very concerned about the needs of the employees. Because Elenez had health problems, Maltos tried to make sure that she felt comfortable and was able to function at the new clinic. Maltos installed bulletin boards in each of the suites and he checked on all the suites daily.

Herlinda Valenzuela, a Yaqui activist who helped in the original organization of the clinic, also remembered the move from Mother Higgins to the new clinic. She recalled that some of the family health workers used their cars to help the nurse practitioners move. Although El Rio hired movers, many employees packed their own cars and moved their "stuff". The whole Accounting Department moved much of their own supplies and equipment.

During the first week of Ethel Larsen's employment, the Accounting Department resided in one of the trailers at the original site. Summer days in Tucson could easily remain above 100 degrees Fahrenheit. By the end of each working day, the coolers failed to keep the trailer, in which Larsen worked, at comfortable temperatures. However, a week later the clinic moved to the new air conditioned site and Larsen joined many other employees who used their own cars in the move.

In her new position, Larsen's responsibilities included contributing portions of a federal financial report, managing parts of the payroll records, developing and maintaining control over the billing and recording of funds for the new HMO program, and handling the accounts payable as it applied to the purchase of medical services outside the clinic.

El Rio had established numerous arrangements with outside specialists and hospitals so that the low wage earning patients could get reduced or free service. Larsen maintained control over the myriad of different arrangements. This included frequent interactions with patients who received bills for the services covered by contracts. Larsen had responsibility to deal with any problems that might arise out of non compliance with contractual agreements. Through time Larsen's responsibilities changed and the area of purchased medical services, especially for HMO patients, become the focus of her job.

Physical Area Covered

The new El Rio clinic located on Congress was well situated in the middle of the service area. In the northern part of the service area was a Yaqui community and adjacent to that community existed a large apartment complex that housed many elderly Anglo citizens. Both the El Rio Neighborhood Center and the El Rio Golf Course could be found just a few blocks north of the clinic.

To the south of the clinic lived many Mexican-Americans and in some areas African-Americans. Tucson through the years has had a large Mexican-American population and a small African-American population.

In the downtown area, a few blocks east of the clinic, lived a mix of Mexican-Americans and elderly Anglo citizens. A few years before El Rio, some of the poorer and more ethnic houses in this area had been converted to up-scale real estate resulting in the influx of artisans and professionals of all different ethnic backgrounds. Also east of the clinic and included in the service area was the University of Arizona. Few if any students made use of clinic.

West of the clinic mostly Mexican-Americans, some affluent, lived on "A" Mountain. Further west lay the "A" Mountain Neighborhood Center. This area had an ethnically mixed population which included many African-Americans.

Design of the New Facility

The new health care facility, designed primarily by Dr. Neiman, had octagon shaped modules in which a team of physicians, nurse-practitioners and family health aides could see patients. The physicians and nurse practitioners could each have their own private examining rooms.

Medical teams each worked in several different modules. Within these modules and adjacent to the examining rooms existed small patient waiting areas. The concept of small waiting areas close to the examining rooms evolved to avoid the impersonal aspects of so many clinics. The original plan called for team's secretaries to be located within modules in central locations.

Outside of the modules but within the middle of El Rio, facilities such as medical records, laboratory, health education and social services provided valuable ancillary services.

The administrative and financial offices could be found at the northern end of the facility.

In an attempt to tie community interest to the clinic, an auditorium seating up to 200 people was included in the original plans. This auditorium could be used for community as well as El Rio meetings. The auditorium could be partitioned into smaller units for use in group therapy, health education and what was later to be Labor/Management Negotiations.

In the Community

The late 60's and early 70's was a time of great transformation and much activism. Throughout the nation, the emotions of the civil rights movement waned as opposition to the war in Vietnam grew. While the war on poverty was ultimately lost in the jungles of Vietnam, some people used these times to pull themselves out of the gutter and dedicate themselves to change. Others gave up a comfortable middle class life of plenty and dedicated themselves to social modification. At times awful clashes between those dedicated to moderate change and the newly emerging activists who hoped for more dramatic change imperiled peace within the community. Into this equation, however, were also some who sought the pursuit of power. This mix of people were all present in Tucson.

Salomon Baldenegro, born in 1943, grew up in the Barrio Hollywood area of Tucson and had been a school dropout and a member of the gang known as the "Untouchables." He had been a very angry young man. His views might have been colored by the intense anti-Mexican prejudice that was ubiquitous when he was young. Baldenegro's colorful past drew the interest of a local newspaper, The Arizona Daily Star, which reported extensive on his harsh background. The story asserted that Baldenegro once recalled always being in trouble, doing drugs and roaming the streets. "I must have been arrested 75 times." Ultimately, Baldenegro landed in reform school at Fort Grant in Arizona. Shortly after he got out of reform school, he got into trouble again but avoided a trip to the state prison by pleading guilty to a lesser charge and promising to return to high school. At age 22 he managed to complete high school and went on to the University of Arizona. At the university he joined a Chicano student group but had to leave the group because he had become too controversial, according to the newspaper's account. After running unsuccessfully for the Tucson City Council, Baldenegro worked in several social service jobs and in 1973 became the Director of the Youth Services Bureau.

The newspaper story went on to say that at age 27, about the year 1970, Baldenegro led a group that originally was known as the "El Rio Coalition Front". Tovar was also in this group. The group petitioned the city to stop development of the land on West Speedway from becoming the El Rio Golf Course. The rationale, and a worthy one, charged that the neighborhood had inadequate recreational facilities and that a golf course primarily serviced people from outside the area. Reportedly, at a city council meeting, the activists let known their intention to have a non-violent action "if the city does not convert the golf course into a park for the poverty area surrounding it."

In September of that year, seven demonstrators, including Baldenegro, were arrested and given felony charges after they had interfered with police giving out a traffic ticket. Baldenegro's wife was also arrested and charged with being loud and profane during the same incident.

A group of fourteen families met that same day and formally disclaimed what it called the 'violent faction' of the group. Now two groups vied for a community park: The El Rio Coalition, made up primarily of the fourteen families, and the newer, younger "People's Coalition". Baldenegro and his wife belonged to the more radical group, "The People's Coalition." They claimed that their action of interfering with the police came only after significant provocation.

In time, a compromise prevailed and the community did get a park area with facilities for classes and social activities. It was to be called the El Rio Neighborhood Center. And it did become an important resource for the community. The golfing community got a part of the park area to be used as a public golf driving range and public golf course.

Isabel Abalos started working at El Rio later, during a time of high turmoil. She heard whispers and people in little groups talking. No one took her aside to explain anything. Abalos felt very left out. Abalos knew Tovar from her earlier volunteer work in support of the farm workers. At that time she had heard good things about Baldenegro. When hired by El Rio, Abalos went to Tovar to find out about the undercurrent activities. Tovar warned her to just listen and learn. Later, Abalos became aware of negative things about Baldenegro. She believed that Baldenegro had been responsible for the cut in funds for Cowen's work. Abalos began to see Baldenegro as being vindictive and spiteful.

Larsen, at first, thought positively of Baldenegro. When she expressed her belief to some of her Mexican-American co-workers, she was surprised at their emotional negative response. In time, Larsen's view changed as she became more aware of his actions. Larsen believed that some minority communities suffered damage from dynamic leaders who used both the times and their community to achieve a power base for their own self interests. She thought of these people as "poverty pimps." As she came to learn that many of the Mexican-American employees were frightened of Baldenegro, she began to think of Baldenegro in such a light, as a poverty pimp.

While some employees such as Bishop thought that of Baldenegro as vocal and opinionated - the "leader of the pack", others at El Rio had a positive view. Pat Morris thought of Baldenegro as someone in the community who fought for Hispanic rights. Morris also believed that Baldenegro wanted to help other minorities, not just Hispanics.

In early 1972, shortly after Nixon's election to his second term, the concern arose that the president planned to terminate the neighborhood health center program. Abrams had been advised, by a former Assistant Secretary of the Department of Health, Education and Welfare (DHEW), to take the necessary steps to phase out El Rio in such a way as to not disturb the Hispanic community. But the Watergate scandal was about to fully emerge. Overnight the first threat to close neighborhood health centers dissolved.