The Lower Rio Grande Valley lies more than 300 miles from Austin, but in this southernmost region of the state, the influence of UT pharmacy casts a deciding orange beacon.
The region, known as RGV, includes Starr, Hidalgo and Cameron counties that lie west to east along the U.S.-Mexico border as well as Willacy County just to the north of Cameron. Once viewed as a sparsely populated outpost, the area is now home to more than one million residents, including many whose families have called this area home for generations and others who have settled there in recent years.
Despite its name, the area is actually a delta, not a valley, resting on the northern banks of the Rio Grande River. Early settlers to the area, however, felt that the term "Valley" sounded more inviting to tourist and prospective investors and the term as remained.
It is an area of contrasts. Upwardly middle class and affluence co-exist alongside pockets of severe poverty. Approximately 45 percent of the population who are age 25 years and older have earned a high school diploma while the unemployment rate in this area has reached double digits. The two state universities in the area, UT Brownsville and UT Pan American, have a combined student enrollment of approximately 32,000. The area is decidedly Latino, but career opportunities have brought professionals of all nationalities and cultures to the region in recent years.
Hidalgo County, located in the geographic center of the area, is home to McAllen and Edinburg. A recent story by Forbes magazine cited the McAllen-Edinburg-Mission area as the number one mid-sized location in the country for jobs with a 48 percent increase in education and health-sector jobs since 2003. Despite the availability to jobs, many local residents are undereducated and lack training to fill the positions.
Most of the valley's commercial, retail and healthcare development lies along U.S. Highway 83, known as the Expressway. This major transportation artery has been described as "the longest main street in the world" as it winds its 100-mile path from Rio Grande City in the west until its end at the Texas-Mexico border in Brownsville. Along the corridor, name brand retail centers bump into one another with such frequency that it is difficult to determine where one community ends and another begins. An impressive array of large hospitals and health care centers are interspersed among the thriving retail landscape.
The bustle along Hwy 83 quickly gives way to sparsely populated areas where farmers and ranchers wrestle daily with the arid climate. Despite the appearance of affluence along the Expressway, the area has been deemed one of the poorest in the country. Many of its residents work in low-paying jobs that do not offer health insurance benefits. Workers earn enough to make them ineligible for government supported insurance such as Medicaid and CHIPS. Their lack of insurance often causes them to turn to self-medication or alternative treatments to avoid costly visits to physicians. Still others suffer from chronic illnesses such as diabetes or hypertension and cannot afford medications and medical supplies to monitor their conditions. Many do not seek professional medical assistance until they are ill and end up in hospital emergency rooms. This has led the area recently to be identified by New Yorker magazine as one of the most expensive health care markets in the country.
The Valley has an acute need for more health care providers including pharmacists. According to a report issued by the Texas Higher Education Coordinating Board, the region has an average of 49 pharmacists per 100,000 residents. This compares to the state average of 74 pharmacists per 100,000 residents.
In an attempt to help address the need for more pharmacists, the College of Pharmacy partnered with UT-Pan American in Fall 2000 to establish the Cooperative Pharmacy Program. The program is designed to encourage area students to consider pharmacy as a profession. Students may apply as early as the end of their high school career. Once accepted, they complete their first two years of pre-pharmacy course work at UT Pan Am, move to Austin for the first two years of the professional program, then return to the RGV to complete their third and fourth years of the pharmacy curriculum. The program is often described as the 2 + 2 + 2 program.
Amy Schwartz, assistant dean of the Pan Am Cooperative Program, says that the program is making a difference. Since its conception, more than 30 area residents have graduated as coop students. Of those graduates, approximately two-thirds have established careers in the area. Several others have opted for advanced training through residencies and fellowships and some of these scholars may yet return to the Valley for their professional practice. The first class to complete all six years of pre-pharmacy and pharmacy education graduated in 2007. Approximately 45 students are currently in the Cooperative Program.
Since the program's inception, Valley pharmacy students have provided approximately 1,500 hours of volunteer time at various agencies across the Valley including Comfort House, Vannie Cook Cancer Center, Hope Family Health Services, Cu Clinica Familiar, Neustra Clinica Familiar and the March of Dimes.
Program faculty have also been involved, providing clinical and professional services to community clinics and hospitals including Rio Grande State Center, McAllen Heart Hospital, Tropical of Texas MHMR, Su Clinica Familiar, and Spaulding for Children.
Coop students find trusted mentors in Schwartz and Patricia Canalas-Gonzales, clinical associate professor, who meet regularly with the students to advise them concerning course loads and offer tips on how to manage the stress of college. They also supervise the students during their final two years of the program.
"Many of our students have not left the area for any length of time, and some are among the first in their families to attend college," said Schwartz. "There's a lot of apprehension about moving to Austin, even if it's only for two years."
Schwartz says she maintains contact with the students while they are in the first and second professional years by traveling to Austin herself at least once each semester. There she checks in with the students and helps make sure their transition is smooth.
"I try to be a face from home for them," she said.
"A lot of parents in this area who didn't go to college themselves encourage their children to consider health professions," explains Canalas-Gonzales. "There is an understanding among the elders that health care will always be needed – that as a profession, it's a sure thing."
Schwartz and Canalas-Gonzales also point to the contributions of area UT pharmacy alum that serve as mentors to prospective and current students. People in this area not only know one another, they know their families and their history, they explain.
"They share and connect to one another," said Canalas-Gonzales.
To help channel that connection, an advisory board for the cooperative program is planned.
Representatives from area pharmacy outlets and leaders in the Valley communities will be invited to serve on the board that will begin meeting quarterly in the near future.
Schwartz admits that there have been unique challenges to the valley cooperative program such as recruiting faculty. Both Schwartz and Canalas-Gonzales hope to soon attract additional faculty candidates. Currently one staff member, Anna Olivarez, provides administrative support for the entire program.
"The day to day operations and challenges of the program sometimes make it difficult to see our progress," admits Schwartz, "but when I stop to think about the number of our former students who are now in successful practices in the area, I know we are making a difference."
The McAllen office of Isidro Ramirez, Pharm.D. '03, lies in the east-west center of the Valley, just a stone's throw south of Highway 83. A clinical pharmacist with the Rio Grande Regional Hospital he also sits in the heart of the increasing presence of longhorn pharmacists in the area.
University records indicate that he is not alone with more than 250 area pharmacists listed as earning their degree from UT including 85 in Cameron and Willacy Counties and 157 in Hidalgo and Starr Counties.
"I was always interested in attending UT," Ramirez recalled. "When I graduated valedictorian of my high school class, I began to look closely at UT. I was good at math and science and was interested in a profession where I could work with people. When I found pharmacy ranked among the top programs, I knew that was the profession I wanted to pursue. It was the best thing I ever did."
Ramirez's second floor office reflects his allegiance. Bevo beverage coolers, longhorn football helmets and even a plastic burnt orange fish have taken up residence on his desk and shelves. A UT preceptor pin and the pharmacy alumni pin shine prominently on his lab coat.
His class pre-dated the area's cooperative program, but he adds that his classmates included the first students from the El Paso Cooperative Program. He returned to the Valley for his fourth-year rotations working closely with Dr. William McIntyre, who recently returned to the college as associate dean over clinical programs. Ramirez left area practice for one year to work as a faculty member with the Pan Am program. Missing the hospital environment, he returned when his current position became available. He also serves as a clinical coordinator for the internship program.
Ramirez credits his family pharmacist Lino Perez, B.S. '62, of Roma, as first planting the seeds of a career in pharmacy.
"My brother had cerebral palsy," Ramirez recalled. "We would take him for medical care in another city. When we returned home, we often had a new prescription to fill. My family would go to Lino's Pharmacy and Mr. Perez would open the pharmacy, day, night or holidays, to make sure we had the medications my brother needed."
Ramirez is not the only pharmacy student who was mentored by Perez.
"I have been a pharmacist for the past 47 years and 30 of those years I was fortunate to be a self-proprietor in the city of Roma," Perez said.
"I am so proud of being a UT graduate and that I had the good fortune of sending at least 12 letters of recommendation for students interested in attending pharmacy school," he said, adding that 11 of those applicants were accepted as students.
One of those students, Jesus Rios Jr., B.S. '96, brought his pharmacy four years ago. Perez said he was honored that the new owner chose to continue with the name Lino's Pharmacy. He has since opened Lino's No. 2 in Rio Grande City.
"I've known Mr. Perez all of my life," Rios said. He was my inspiration and motivation to become a pharmacist. I am grateful to continue his legacy in providing pharmacy services to our community. My goal for the future is to inspire others to become health professionals like Mr. Perez inspired me."
"My hope had always been that one of my children would follow in my footsteps," he said, adding that although none of his four biological children pursued pharmacy practice, "God has different ways of answering you dreams, and 11 UT pharmacy graduates of whom I personally recommended were God's answer to me. I am glad I could be at the right place to help them."
"I've never forgotten what he did for our family and his compassion for his patients," Ramirez said. "In one way, my entering pharmacy was a way to give back to the community some of the care my family has received."
In his position as clinical coordinator of pharmacy services for the 320-bed Rio Grande Hospital, Ramirez works in direct patient care activities, oversees formulary controls, presents staff continuing education opportunities, makes presentations to doctors and other health care professionals as dictated by the hospitals ever growing clinical initiatives, and precepts pharmacist interns at every opportunity. Ramirez has also recently attained Board Certification in Pharmacotherapy and stresses that all pharmacists should strive to continue to learn and grow in order to maximize their potential as key healthcare providers in their communities.
"There are great jobs in the valley for pharmacists. All students who decide to stay have several job opportunities," he said. "Even with the addition of other pharmacy education programs serving the area, the jobs opportunities remain."
Annette Ybarra Ozuna, Pharm.D. '04, was another who benefitted from Lino Perez's mentorship. As a child she came with her family to Perez' pharmacy. She distinctly remembers coming there for Perez to administer her allergy shots. Later, she was one of the students for whom he wrote letters of recommendation.
She finished high school and enrolled at UT Pan Am for her two-years of prerequisite coursework before transferring to UT for her four years of pharmacy school. In her final year of internship training, while in a hospital rotation at Rio Grande Regional, she noticed a young pharmacist practicing at the hospital. Annette was under the direction of another mentor, but Ronnie Ozuna, Pharm.D. 2000, caught her eye, and she caught his. Soon after completing her rotation, the two began dating. They married in September 2005.
Annette also had an internship at WalMart and began her career working there after graduation. The last year has been a busy one for the couple. Within the last 12 months, they welcomed their second child, built a new home, and opened their own business, I Care Pharmacy in Palmview.
"It's been a little busy, but it's all been good," Annette said. The first few months of the business were a little slow, but Annette said the slower pace gave her and Ronnie an opportunity to really talk with their patients, to get to know them. Their business shares a common lobby, but is not directly associated with a doctor's clinic in a neighborhood retail center.
"Sometimes the patients drop by to say hello to us even before they sign in to see the doctor. It's nice to have that relationship with our patients," she said.
Ronnie, who also serves as the clinical coordinator at Doctor's Hospital at Renaissance in Edinburg, came from a family of educators. It seemed only natural for him to turn to teaching future colleagues by becoming a preceptor. Annette says he is known for expecting a lot from his students, a reputation for which Ronnie offers no apologies.
"I don't want students to come to the valley and think they can relax," he said. "I want to assure clinical professionalism among the students."
Patients, he says, deserve nothing less and the growing reputation of the valley as a regional medical center demands nothing less from the pharmacists who will practice there.
Annette, too, plans to become a preceptor, now that she and Ronnie are getting the hang of the new home, the new business, and the expanded family.
One of Annette's high school classmates was Rose Mary Silva, Pharm.D. '05. She, too, grew up in Roma and knew Lino's Pharmacy.
"My vision of pharmacy was of the independent pharmacist I knew growing up," she said. "He had the only pharmacy in town and knew all of his patients. Since I was a junior in high school I knew that I wanted a career in pharmacy. I also knew that I wanted to work closely with my patients just as my hometown pharmacist did."
Silva said there was never any doubt that she would return to the valley once she completed her education. Upon graduation, she took a position as a relief pharmacist with WalMart, a position she said gave her an opportunity to continue learning from many different pharmacists in the area. Soon she was named pharmacist-in-charge of a brand new WalMart pharmacy.
"When the store first opened, it was a little slow," she recalled. "This gave me a chance to really get to know our patients, just like Mr. Perez knows his."
She said that WalMart has been very supportive of her continuing to take time to counsel and know her patients, making for a satisfying practice environment.
She married a public school teacher, Pablo Rodriguez, who decided recently to make a career change. He's now a pharmacy student.
Silva said she left the Valley and moved to Austin to be with her husband for one year where, continuing with WalMart, she had an opportunity to work with a deaf patient population due to the store's proximity to the State School for the Deaf.
When Pablo finished his first year, the couple decided to build their first home so Silva transferred with WalMart back to the valley to allow her opportunity to oversee construction of the house.
"Pharmacy is a self-rewarding career," she said. "You have to appreciate what you're doing to help the patients be healthier. It doesn't matter where you live or how much money you have, good health is important to everyone. I like knowing I can help make a difference in the lives of my patients."
Michelle Martin Salinas, Pharm.D. '08, knew from an early age that she wanted to work in health care. Maybe it was the influence of her grandmother, a nurse who raised Michelle. Maybe it was a caring counselor who recommended she consider the area's medical arts magnet school. Maybe it was just something she was destined to do.
Most likely it was a combination of influence and interest that led her to South Texas High School for Health Professions, or Med High. The school, which opened in 1984, is one among several magnet programs in the South Texas Independent School District that serves junior high and high school students. The district was recently designated as one of the top 100 high schools in the nation by Newsweek magazine.
She initially planned to become a doctor, but an internship at Salinas Pharmacy in Harlingen as part of a pharmacy technician course at Med High took Salinas' life in a different direction. At the pharmacy, she learned first hand about the work of a pharmacist under the direction of owner Gilbert Salinas, B.S. '77. There she found an excellent mentor and her career path. She also found her future husband, Gilbert's son, John, Pharm.D. '07, and learned that pharmacy is definitely a Salinas family tradition.
In addition to Gilbert, John and Michelle, the family pharmacy tradition also includes Gilbert's brothers, Albert Salinas owner of Salinas Pharmacy in San Benito and Robert Salinas owner of Los Fresnos Pharmacy. John's cousin, Audrey Valencia, is currently a P-2 pharmacy student at Incarnate Word. Gilbert and John both practice at the family pharmacy and Michelle's mother-in-law, although not a pharmacist, works in the store as well. With the anticipated arrival of Michelle and John's first child later this year, Michelle says her mother-in-law has already offered to convert an area of the family pharmacy into a nursery. Despite this, Michelle says she is not yet ready to sign the expected baby up for pharmacy school.
"We'll have to wait and see," she says with a bright smile.
Michelle works at Harlingen's Rio Grande State Center outpatient pharmacy. The facility provides both inpatient and outpatient services. The inpatient pharmacy services the mental health facility. It is the state's only public provider of mental health services south of the San Antonio State Hospital. "It's a busy place," Michelle says, with the pharmacy often filling 200-300 prescriptions per day.
"We see a lot of indigent patients," she continued. "They can get their prescriptions filled for $7. It feels great to be able to help people who need it. If they're sick, we help. We don't turn anyone away."
Jaime E. Balli, Pharm.D. '07, knows a little bit about serving indigent patients in the Rio Grande Valley. As pharmacist-in-charge at Nuestra Clinica del Valle in San Juan, he oversees the prescription needs for a sizeable portion of the indigent population in Hidalgo County. Balli says his pharmacy fills 550-600 prescriptions daily. One Friday in mid-July, the clinic filled 787 prescriptions. The workload can be overwhelming, but Balli points to the clinic's exceptional staff and the brand new automated dispensing system with pride. The massive piece of technology stores the bulk of the clinic's prescription drug therapies and hums away throughout the day processing the orders as they are entered into the system. The technology helps greatly with the workload, but Balli and his colleagues still must move at a quick pace to keep up with the ever-flowing influx of prescription needs.
The waiting rooms outside the pharmacy are bustling with patients and their families as it usually is every day. Mondays are always especially busy, Balli says, with patients who became ill over the weekend waiting to seek assistance until the clinics reopen on Monday mornings.
Although local, state, and national programs have been initiated in recent years to alleviate dire economic conditions among area residents, the numbers at Balli's clinic speak to the persistent presence of poverty in the area.
The San Juan Clinic is one of the largest of 11 in the RGV supported by the Texas Association of Community Health Centers. In addition to medical services, the clinic also provides full dental services. It sits mere blocks from the thriving economy witnessed along Highway 83, but it is light years away when considering the economic realities of the patients he sees.
In 2008 alone, Balli said the 11 clinics collectively saw more than 32,000 new patients. Of that number, he said, two-thirds were without any form of insurance. Medicaid, Medicare, and private insurance covers most of the remaining patients. The average per capita income in the area remains at just over $9,000, and it is estimated that more than one-third of the population lives at or below the poverty level.
Patients pay a sliding scale, the minimum of which is $5-7 per prescription if they can afford to do so. Grants and donation programs with several large pharmaceutical manufacturers support the program with donated drugs. The clinic charges, Balli said, are aimed at recovering the dispensing costs of the medications. To help save money, the prescriptions are distributed in brown paper sacks, a steady stream of which sit beside Balli's desk waiting for his review before they are distributed to patients. Those who cannot afford the fees are sent to a clinic social worker who addresses each case individually to attempt to secure the needed medications by contacting the drug manufacturer directly.
He works closely with Ernesto Esparza, B.S. '65, who serves as director of all pharmacy operations at Nuestra Clinica del Valle. Some of the pharmacies in the clinic system are Class D pharmacies. Prescriptions that these pharmacies are not authorized to distribute come to Balli's pharmacy for processing.
Balli's father worked in the clinic for many years to support his family, and Jaime remembers going to work with his father as a child.
"I always knew I'd leave the area to go to school, but I also knew I wanted to come back," he said. "When I heard about the pharmacy cooperative program, I knew it was heaven sent for me."
When he graduated from pharmacy school, he said he checked on job opportunities with the clinic.
"I wanted to be somewhere where I was needed the most," he said. "I know I make a difference here. The patients are wonderful. They're very appreciative and always say thank you. It feels great to know I've helped them."
Balli says the clinic is constantly looking for new space to expand. "Wherever there's a need, we expand and do our best to serve these patients." he says as he turns back to the growing stream of prescriptions awaiting his review.
To learn more about the Pharmacy Cooperative Program, go to http://www.utexas.edu/pharmacy/edutrain/pharmd.html.
For specifics about the program in the Rio Grande Valley, contact Dr. Amy Schwartz, assistant dean, at (956) 318-5221 or go to www.utpa.edu/programs/pharmacy.