PAHALA — It is the kind of town where the ATM occasionally runs out of money, and the gas pumps, too, so make sure not to let the tank fall to zero. The kind of place where store closing times are flexible if a family event is happening. Home to generations of people who worked for Ka‘u Sugar Company, and now home to their sons and daughters, grandchildren and great-grandchildren.
Pahala, population 1,291 according to a 2014 U.S. Census estimate, is a tight-knit Big Island outpost, just about 20 miles away from the nearest town in either direction. 54 miles away from Hilo, 70 miles away from Kona.
It is home to the Ka‘u district’s only hospital and emergency room, a modest one-story building painted pale green that sits on a hillside above Highway 11. The same building houses the Ka‘u Rural Health Clinic.
“It’s easy to just blow right by it,” said Dr. Curtis Lee, a Hilo-based nephrologist who visits the hospital twice per month to meet with anywhere from five to 10 patients.
Chronic conditions like diabetes and renal disease are common in Pahala. Specialists, as is the case around the island, are not. Lee’s extra miles make an extra difference.
The entire state of Hawaii suffers from a lack of physicians, but even in that context Ka‘u has a lower than average number of medical providers, said hospital administrator Merilyn Harris.
“We’re a medically underserved area; we have that designation for the entire district,” she said. The hospital is one of three federally designated Critical Access Hospitals on Hawaii Island (the others are in Honokaa and Kapaau). Critical Access Hospitals are located in rural areas, and receive federal funding each year to support their aim of boosting health care services.
The Ka‘u emergency room and its four ER physicians admit about 2,700 patients per year. The rural health clinic next door sees about 4,900 patients annually.
Both are part of the Hawaii Health Systems Corporation’s East Hawaii Region, which includes the Hilo Medical Center. That affiliation enables access to everything from human resources support to electronic medical records (the hospital has used EMR for years; in December, the rural health clinic will become the last in HHSC’s system to make the shift).
Combined with the CAH federal funding and an annual $1.7 million in state subsidies, it’s created a sustainable model for the hospital and clinic. Staffers would like to do more — bringing in a CT scan machine, for starters — but for now, they work with what they have.
The hospital is important, said lifelong Pahala resident Clayton Avenue, whose wife is a retired nurse. “We need some kind of support (here).”
In Pahala, the support goes both ways.
“It’s very encouraging to see how the community stands behind the hospital, because the hospital, like the community, has limited resources — but the community steps up to support them.” said Dr. Cary Gear, a family practice doctor and the newest physician at the rural health clinic.
‘Giant community project’
When Pahala was home base for the Ka‘u Sugar Company, its plantation hospital was one of four in the Territory of Hawaii to be rated Class A, according to the University of Hawaii at Manoa’s plantation archives.
The current facility was built in 1971. There used to be sulfur dioxide monitors installed in the building, keeping everyone apprised of vog severity.
It wasn’t until after 2009 that the building received a complete renovation — and central air conditioning — thanks to $4.7 million in special state funds secured by the late state Rep. Robert Herkes.
Help also comes in incremental ways from the people who know best what the hospital needs.
Cardiac monitors, a ventilator, and pediatric equipment in the emergency room were purchased through community fundraising — spaghetti dinners, craft sales, bake sales, golf tournaments. Service groups like O Ka’u Kakou and the Volcano Rotary Club built a lanai for long-term care patients and painted the building. The hospital also works with the Ka‘u Rural Community Health Association.
“Basically, I feel like we’re this giant community project,” Harris said. “That kind of inspires us, because they show that what we do is important, and so it makes you want to do better, do more. We’re always looking to improve access to care.”
Part of that effort was hiring another full-time family practice physician for the rural health clinic. Gear came on board in December, making the move from Indiana.
A little added help
“I no longer can say ‘I’m the doctor in Pahala,’” Dr. Dexter Hayes said on a recent Wednesday. She wore a wide smile and a button that said Ask Me If I’ve Washed My Hands. “I’m one of the doctors.”
Hayes has been at the rural health clinic for five years; she moved to Ka‘u from Arizona. There have been other part-time physicians in that time, but no full-time family practitioners.
“Before that it was just me,” Hayes said. She was seeing her own patients in addition to walking across the building to visit long-term care patients and working with patients in the hospital’s rehabilitation and physical therapy programs. The latter service is a relatively new offering, put in place mainly so older patients and their spouses don’t have to go to Hilo regularly.
The work was worth it, Hayes said, but it was a lot for one person to tackle.
“Having Dr. Gear here — oh my gosh, it’s so much nicer,” she said.
But since physicians are hard to come by around the state, how do you find someone who can handle the extra challenges of working in rural health?
It helps if their whole family comes, too. It wasn’t just Gear and wife Kim who made the move to Pahala in December. Both daughters, along with their husbands and children, moved as well.
The family had ties to Hawaii going back to territorial days (Kim Gear’s father was stationed at Pearl Harbor), and in recent years had started coming to Kona to work at the Youth With A Mission campus in preparation for mission trips to places like Cambodia and China. Most recently, Gear took a team to Zambia to do HIV/AIDS education.
He also wrote a proposal for starting a medical clinic at the YWAM campus, and returned with Kim to get the program up and running. They later decided they wanted to move to Hawaii permanently, but even then, the rural health clinic wasn’t high on the radar.
“This job came up, and initially I thought ‘This is really pretty isolated; I’m not sure we want to do it,’” Gear said. During a different interview on the island, he decided to stop by the clinic and say hi.
“I came in and met the people, and they were just so nice and (everyone) was so friendly,” he said.
We really need to consider this, he told his wife.
Setting roots
Gear and his wife are now renting in Pahala and living out of their suitcases until they find a home to buy (their household goods are in mainland storage). His daughter and son-in-law are restoring a home up the street. His grandsons have joined the karate class led by Dr. Clifford Field, the Ka‘u Hospital director.
“We wanted to be in a place where you could feel part of the community,” Gear said.
Working in rural areas requires “the right heart,” as Harris put it. But it’s also not a job for the idealistic novice.
Both Gear and Hayes have more than 20 years of medical experience. And they draw from that bank of knowledge every day: rural physicians, like the communities they serve, must be self-reliant because they don’t have the resources of larger areas (Gear said he’s eager for the December EMR transition date to arrive).
“This would be a hard place for someone right out of residency to come,” he said. “You’re making decisions on a whole different basis here.”
Decisions are made knowing that ordering a test might mean someone has to make a three-hour round trip just to get to the right facility. Can that someone afford the gas? Can they afford to take the time out of their day?
Making those decisions, and knowing enough about patients to make them confidently, is part of the draw.
“That’s, to me, what is so appealing about rural medicine,” Gear said. “You’re not just ordering the test, but you’re in a sense a member of their family, and you get to know them, their brothers and sisters and aunties and uncles.”
“You see them at the grocery store, you worship with them at church, and it just adds a whole new dynamic,” he said. “It adds something to medicine.”
Email Ivy Ashe at iashe@hawaiitribune-herald.com.