DR. LAURIE DEKAT HAS A COLD AND SHE’S PREGNANT with her second child and her back aches and there are a dozen mothers, infants and teen-agers in the waiting room of torn vinyl chairs and desperate lives at the West Dallas Youth Clinic. It was like that for her in Guatemala, too-always too much to do for too many people. You could start feeling sorry for yourself except there wasn’t time for self-pity in the Third World. There isn’t in the projects or the barrios of West Dallas, either. Lots of "the Lord’s work" to be done right here. That’s what Dekat’s boss, Dr. Ron Anderson, calls it. That’s the way the hospital he runs, Parkland Memorial, looks at ministering to the city’s poor, too.
So it wasn’t that hard for Dekat to give up her idea of returning to Central America as a Catholic missionary. Her Dallas clink-one of a prototype of community health outposts being developed by Parkland-is in the front lines of a war against what Anderson calls the "incubators of poor health. " He means communities in the city, nation or world whose conditions produce illness, trauma and death. The "incubators" are not only devastating the people who are trapped there, but also straining the resources of hospitals, doctors and taxpayers. But if the outposts work-and governments and public health organizations everywhere are watching closely- the war can be won. So Dekat isn’t just a missionary, she’s a soldier. As for returning to the Third World- these days you don’t even have to cross the Trinity, much less the Rio Grande.
Still, this is a tough day. Now there’s Damon (not his real name), a fast-moving 17-year-old who has pushed his way past the reception desk and into her office. In his skewed blue ball cap and shiny sports windbreaker he could be any black teen-ager from the projects along the banks of the Trinity River, and maybe he is. He’s also a 17-year-old with bad kidneys and they’re backing up on him, making him bloated, hyper and scared.
So he’s determined to see Dekat. He’s already been to Parkland but got freaked out waiting for tests and took the bus back down to the West Dallas Youth Clinic, just around the corner from Pinkston High School on North Hampton. The clinic is smaller, more personal and more friendly than Parkland. It’s supposed to be. "Non-traditional care in non-traditional settings’-that’s the whole idea of the program Parkland began pioneering in 1989.
Usually known by its acronym, COPC-Community Oriented Primary Care-is the cutting edge in a major public health shift toward preventative strategies. Better, less expensive and more comprehensive than the community health models that emerged via federal programs in the 1960s, Parkland’s clinics, the only full-fledged COPCs in the country, are likely to become the new federal models by the end of the decade. They are the future, and they work. A slice of proof is Damon’s insistence that Dekat, not some faceless resident at Parkland, deal with him. After all, she’s his doctor. That’s as it’s supposed to be, too. But for these tests, she can’t be. The COPCs are designed to provide front-line, primary care-not to replace hospitals. They’re light cavalry, not heavy armor. Parkland still gets referrals and still handles emergencies.
Dekat puts her arm around Damon to comfort and calm him, and walks him into an adjacent examining room, trying to explain how it is. He doesn’t want to go back to Parkland to keep his appointment, but she insists. It’s touchy for a few moments. He’s more agitated than she’s ever seen him-really jumpy, talking a mile a minute. She has to administer more than medical advice-she has to be his friend, his mother, his counselor. She’s also got to save his life.
If he wants to get well he has to keep his appointments, take his medicine. Otherwise, though she doesn’t tell him, he’ll die sooner or later, from complications of a treatable disease. The poor tend to do that-become crippled, blinded or killed by preventable illnesses like diabetes or renal failure. Or they’re stroked out by hypertension, eaten by cervical cancer twice as often as better-off neighbors, numbed by infant mortality rates as bad as in Guatemala. Dekat has seen all that too often. So have the other 28 doctors now working in the six COPC clinics in West Dallas, East Dallas, South Oak Cliff and Parkland itself. But three years into one of the boldest efforts to solve the American health care crisis and they’re seeing it less than they used to.
Dekat escorts Damon out the door, wondering when and in what condition he’ll be back to see her. "You get attached to some kids. There’s no other real profession, except maybe the priesthood, where people allow you so much into an intimate part of their lives." She adjusts her glasses and arches her throbbing back. Mothers and children are stacking up in the day room, and kids clutching school passes are walking in from Pinkston. "If he misses his appointment, " she says, "I’ll call his grandmother and find out where he is."
DR. DAVID SMITH WASN’T PLANNING ON coming to Texas, nor was his wife Donna Bacchi-Smith, also a pediatrician, but the National Health Service posted him here anyway. He’d been in residency at Children’s Hospital of Philadelphia, but he still had to work off his Cornell medical school loan, kind of like the young doctor on Northern Exposure. But Smith’s exposure was going to be considerably further south: the impoverished colonias of Brownsville in the Lower Rio Grande Valley.
At first, Smith "wasn’t a happy camper, " but his resistance to exile gave way to an anger that changed both his life and that of his wife, also in NHS service. "One of the first things we saw was that there wasn’t even any potable water, " Smith later recalled. "Kids were suffering from preventable disease. " Had he and Donna not seen the conditions with their own eyes, they might not have believed them. "We learned, " he said, "to be incensed about many things."
Even his own profession fueled the anger. As director of the federally funded Brownsville Community Health Center, one of the early models of low-income health care, Smith was seeing about 27 percent of the patients in the area. But only at the clinic. The city’s main hospital, Brownsville Medical Center, refused admitting privileges to the clinic’s physicians, leaving the nearest hospital for the indigent in Galveston, 400 miles away.
The idea that began to change Smith’s life and career, and eventually the health landscape of Dallas, began to take hold. The problems didn’t begin or end in the examining room-they went far into the social fabric. He began to perceive a linkup between health and politics.
So he ran for the Brownsville school board.
Almost from Smith’s arrival. Brownsville hospital officials had been leaning on friends in the city council to help get rid of the meddlesome NHS doctor. And they might have done so, except for a decidedly unmedical flanking manuever. When Smith learned that the school board had tremendous influence on the hospital through various public contracts, he saw a way to counteract political enemies on the council and elsewhere. A place on the school board might force the hospital hierarchy to come to him.
Smith won the seat. Before long, the city hospital changed its policy to allow physicians from the community clinic to admit and treat patients. But that was only the first of many battles. Working with his wife and other progressive health care workers, Smith went after an all-too-familiar array of troubles; a 50 percent dropout rate in the schools; rampant drug use; teen-age pregnancies. Most of the time, solving one problem meant also solving another.
Next thing he knew, he and Donna, both now bilingual, had been in the Valley three years. "If I’d gone back to Pennsylvania, like I planned, 1 would have gone back into academic medicire, " he recalled. "But now I saw how I could do more good. I’d make less money but do more good. My wife felt the same way."
On a trip to Austin in 1985 to testify before a legislative committee about the needless death of a colonia baby. Smith met a passionate doctor whose views he would come to share, emu ate and advance. This doctor wasn’t just a "enegade, he was the head of Parkland Memorial, one of the most powerful hospitals in Texas. Dr. Ron Anderson took a liking to Smith, too. They kept in touch, even after Smith was promoted to Washington in 1987 to become medical director of the public health service’s Community and Migrant Health Center operation, overseeing 600 community clinics around the country.
That same year, the Dallas County Commissioners Court endorsed Anderson’s plan to make COPC the new model for Dallas public health care. If fully realized, the plan-preventative clinics in eight targeted "incubator" communities-would fundamentally improve the quality, quantity and costs of health care in the city, on a continuum stretching from birth wards to trauma rooms
Anderson knew exactly whom he wanted to head the project, and it wasn’t long until he got him. By 1989, David Smith was back in Texas. His experience in Brownsville and Washington had convinced him, as it had Anderson, that the country’s health problems could not be solved simply by bringing in more money, or tinkering with financing. The entire system had to be changed. "I believed in the COPC concept before I ever came here, " Smith said later, "but the thing that intrigued me about Dallas was that Parkland believed in it. It was like having a 600-pound gorilla on your side."
Within two years, six of the eight projected COPC clinics were in operation. The first to go on-line was the West Dallas COPC complex, which actually expanded and combined the more limited operations of three existing neighborhood clinics-Saldivar, Carver and the Youth Clinic-which had been run since 1968 under the former Children and Youth Project of UT Southwestern Medical Center. Partly because of its long history, West Dallas is the only COPC site still not consolidated in one building. (Parkland counts each clinic as a COPC, but they actually operate as a unit.) The next COPC facility, known as the East Dallas Health Center, also evolved from a pre-existing neighborhood clinic. It formally became a COPC-which meant it could offer more services than it did as a traditional community clinic-in 1990.
Last year, Parkland took the COPC program to its next stage-it started a clinic from ground zero, Smith hired former Cook County emergency room administrator George Newby from Chicago and told him to supervise a COPC project that would become a mode! to the world. The resultant $4. 5 million Bluitt-Flowers Health Center perches on a small hill near South Oak Cliff High School like the finest private medical clinic in North Dallas.
Inside the one-story brick structure, a user-friendly corridor leads patients around an open atrium past brightly colored specialty modules. Each offers a different outpatient service. Workers at one module, for example, treat prenatal patients. Other modules include pediatrics, well and sick baby care, radiology, dentistry, social and psychological counseling, even nutritional guidance. Like all the COPCs, Bluitt-Flowers is a one-stop affair. The idea is to simplify access 10 health care, an especially important factor for the poor, who often have serious transportation problems, or for the working poor, who can’t afford a day off to go to the doctor. The basic charge: $5 per visit with nominal costs for prescriptions. And a DART route comes right to the curb.
At least three more COPC neighborhood centers are on the drawing board-northwest Oak Cliff, Garland and the "Little Mexico" area reaching from Parkland toward Oak Lawn. Residents from those areas, as well as from other parts of town not covered by existing COPCs, currently must seek treatment at Parkland, Some private hospitals, in particular St. Paul, arc providing assistance to the program. Baylor is thinking about lending a hand at the East Dallas Center, Both hospitals, as well as Methodist, have an interest in COPC success, because every hospital in the central city area is affected by increasing numbers of the poor, migrant and unemployed.
From a $250,000 initial outlay, the COPC program is now budgeted at $9 million annually, 56 pecent of which is funded by county property taxes and 44 percent funded by grants or government reimbursements such as Medicaid. If the preliminary results of the COPC models are an indication, it’s money well spent-the program is saving taxpayer dollars.
Early data from the West Dallas COPC, though not fully quantified, seems to show a measurable drop in both teen-age pregnancy and premature death rates in the targeted patient group. Other evidence strongly indicates that children who grew up participating in the West Dallas community health programs-the oldest in the city- during the last 25 years are significantly less likely to become involved in violent crime. Morever, the referral rate to Parkland from West Dallas COPC patients has proven lower than rates in more affluent parts of town. The average length of stay and cost per stay of those patients who are admitted to Parkland also are lower. The bottom line: Treating patients through the COPC system costs only 60 cents for every dollar it would take at Parkland.
The implications for public health are enormous. By 1993, the six COPC clinics are projected to absorb over 200,000 outpatient visits per year, about twice the volume from 1990. Parkland, meanwhile, expects even more than its current barrage of over 500,000 outpatient visits-71 percent of them uninsured-at the central hospital in the coming year, a near doubling of volume since the mid-1980s. In 1990, Anderson says the COPCs saved the system about $2 million by diverting about 100, 000 visits from the costlier care of the main hospital. If that ratio holds for 1993, the savings should be at least $5 million. Looked at another way, the COPCs generate savings equal to about half the program’s own budget. And that’s only in the short term.
As for quality of care, surveys have shown nearly unanimous preference for the satellite clinics. As one 66-year-old African-American woman being treated at Bluitt-Flowers for diabetes, hypertension and heart trouble remarked, "I’d rather come here for everything if I could. At Parkland you have to stand in line for hours and hours."
The success of the COPCs seems almost Utopian in a world overwhelmed by health care crises, In the United States alone, the health "industry" has skyrocketed to nearly $800 billion annually, consuming about 13 percent of the GNP. Insurance costs have become so prohibitive that in the Dallas/Fort Worth area alone up to three-quarter of a million people have inadequate health insurance or none at all. In Texas, about 4 million people, or 26 percent of the population, are without any coverage. The figures continue to mushroom nationally-an estimated 40 million Americans have no coverage and another 50 million have very little.
It’s no wonder that delegations from LA to New York are coming to Parkland to see the COPCs for themselves. Foreign countries have also sought links. One of the most extensive interactions is between Parkland and a poor community in Las Brisas, Venezuela. For the past two years, in cooperation with the University of Dallas and the Centro de Amistad, a non-profit, Dallas-based community service program that initiated the exchange. Parkland has both trained Venezuelan health workers here and sent its own cadres to Las Brisas for feedback.
But the most significant attention may be that coming from the U. S. government. Health and Human Services Secretary Dr. Louis Sullivan is among the many government officials who have toured the COPC facilities. "Health is political." Anderson says. "If we decide health care is a right, that’s a fundamental decision. To achieve it, we have to change our approach to preven-tative or we’ll go broke."
Even private corporations are becoming interested-providing donations or grants. Exxon, for example, has funded a shuttle van to help pick up patients for Bluitt-Flowers. Corporations are also helping influence politicians to support the COPC concept. As Anderson frequently argues, the labor force is shifting with the population. Ignoring the needs of the poor, and of the blacks and browns who assume disproportionate numbers of that designation, means damaging the long-range health of the basic pool of labor. Health care issues are already the source of 80 percent of labor contract disputes. It wouldn’t be good business to let the situation deteriorate further. "We have a societal problem with the health care crisis," observes John Gavras. president of the Dallas Fort Worth Hospital Council. "This [COPC] is one of the ways it could be fixed. It’s incumbent on the industry to look at this. I think it’s morally obligated to look... unless we want the government to lake over health care."

EIGHTY-YEAR-OLD JOSE MARTINEZ had "fallen through the cracks. " as the saying goes. At least 18 percent of the Dallas population lives at or below the poverty line, and those who live way below become like the "disappeareds" of Argentina. They vanish through the cracks at the bottom of the American Dream. We don’t even know their precise numbers because census-takers can’t find them.
It wasn’t that Martinez was terribly sick, but he felt weak and looked pale. He’d tried to get treatment a couple of years ago, hitching a ride early one morning from outside the East Dallas apartment where he stayed with relatives who didn’t really want him. When he finally made it to the outpatient clinic at Parkland, he waited 14 hours without being seen, then went home.
But Martinez didn’t disappear completely. Most days, he could be found in the basement cafeteria of the Brady Center, a seniors day care program operated in the East Dallas barrio by Catholic Charities Agency. It was a good place for the elderly poor to play bingo, watch TV, visit friends, get a hot meal or two and be safe for a while from the spectres of loneliness and violence outside. One morning, lay workers at the center noticed that Martinez seemed listless and pale. After questioning him, they relayed his symptoms to Dr. Larry Irvin, one of the new physicians who’d come to Parkland’s new East Dallas Health Center.
Originally set up by Temple Emanu-el, and subsequently run by the East Dallas Health Coalition until Parkland converted it to a COPC, the clinic opened in 1984 to serve what was then a 60 percent Southeast Asian community but is now 70 percent Hispanic. Pamphlets about breast cancer, smoking and high blood pressure in the modern waiting rooms now come in Vietnamese, Cambodian and Spanish. The faces of the expectant mothers, newborns and teen-agers reflect the diversity, and often the hesitation, of people for whom the very idea of going to the doctor remains alien. Ron Anderson recalls the day a group of young women from the Little Asia community refused to get off the bus at the clinic. "They said they weren’t sick, they were pregnant. They had no experience with prenatal care."
Irvin ordered some blood tests for Martinez. The results showed anemia. More tests revealed that Martinez couldn’t digest B-12. The nausea and sickliness the old man had been experiencing for untold years was a simple problem, with a simple solution-a B-12 injection once a month. All Martinez had to do was show up for his appointment.
Today, on Irvin’s regular Tuesday visit to the center, Martinez is keeping his end of the bargain. But in the COPC system, patients don’t just get rushed in and out. Irvin has noticed that Martinez is short of breath and wants to know why. Martinez admits he’s not sleeping well. Why? He’s not getting along with the relatives he’s staying with. Why? Because he’s old and forgetful. But why does that affect his sleep? In the end. Martinez reveals that the relatives have kicked him out. Where is he staying? "With friends at night. " Irvin knows the answer means Martinez is very close to living on the street. Dignified, polite and proud, the old man won’t come out and say it.
While he prescribes Martinez something to help with sleep, Vicki Urrutia, the clinic nurse, takes notes to pass on to a social worker. Maybe they can find him some housing. As they talk, Irvin asks Martinez to take off his tattered cloth hat, You can sec why he wears it. An oval growth-benign-bulges from the left side of his skull. Irvin measures the growth to see if it has increased in size. It has, a little, but maybe that’s a minor side effect of the B-12 shots. Irvin tells him to come back in two weeks. That’s partly to see how he’s doing medically, and partly just to be sure he’s still around.
The morning goes on. Last in line is a handsome elderly couple in their 80s-he has problems with diabetes, too, and has a chronic nerve problem in his calf. But he’s been coming to the clinic and is in pretty good shape. "If I don’t live to be 100, it’ll be your fault. " he tells the doctor in Spanish. Irvin, an African-American, has learned to speak the language. In the COPC system, 56 percent of the doctors are black or Hispanic, and 65 percent are women.
"The more I’ve become involved the more I like it, " Irvin says, aware public health has long been assigned the bottom rung of prestige on the career ladder. Strangely, that snobbery extends even to the COPC program. Although COPC physicians work for Parkland, they are not, like regular staff doctors at the hospital, also members of the faculty of the UT Southwestern Medical Center. Apart from the professional slight, the exclusion technically meant that COPC doctors couldn’t admit patients to Parkland, because only UT Southwestern faculty can do so. In order to avoid the absurdity of a Brownsville-like conflict in his own hospital, Anderson set up a separate physicians’ corporation, known as CHAMPS2, for the indirect hiring of COPC doctors. That way they could work for Parkland, and thus secure admitting privileges.
"I came to public health because I wanted to change things, " says Irvin, who previously worked for the HMO Kaiser Permanente. "What I’m doing now, 1 can be a part of everything in the health program. Can you focus on just one thing to intervene in the public health? I have to intervene in everything. " Moving a stool closer to the examining table, Irvin sits at the husband’s feet, tenderly cradling the purplish brown flesh in his tireless hands, slowly examining for sores or stiffness.

IF THE MEDICAL ESTABLISHMENT suffers a theoretical split, it is over an emphasis on "medical" or "preventative" models. Parkland is perhaps the country’s most progressive advocate of the latter. The medical model is what we have in America today: latter-end, or curative, treatment involving huge technical capital investments, expensive centralized institutions, physician specialization and a reward system that heavily favors the haves over the have-nots. The preventative model emphasizes early intervention, ongoing maintenance, community and family involvement and personal responsibility. David Smith calls it "pay me now or pay me later."
COPC is directly evolved from the preventative model. Its main ideas are generally credited to Dr. Sidney Kark, an Israeli physician seeking to provide belter treatment to impoverished South African blacks forcibly sequestered in the so-called homelands in the 1940s and 1950s. Kark later took the model to Israeli kibbutzim, and by 1977, when the World Health Organization (WHO) formulated its strategy of "health for all by the year 2000, " the essential components of community-based, preventative, primary-care programs were the building blocks of a global health strategy.
In the United States, however, health care had been taking its own direction. The medical, or curative, approach was ingrained in medical schools and the medical establishment. Though primary-care physicians-the kind who work in COPCs- represented 50 percent of the field in 1963, they accounted for only 34 percent in 1986. Today, less than 1.5 percent of the medical curriculum is devoted to prevention and even less than that to nutrition.
A few preventative, community-oriented programs emerged from the War on Poverty in the 1960s-migrant health, maternal and infant care, neighborhood health centers and, by the 1970s, the National Health Service-but the formidable American health machine was heavily geared toward transplants, bypasses and CAT scans.
A few health care planners began to realize that the COPC ideas developed for the Third World might also be of use to the first. According to the National Association of Community Health Centers, 42 million poor or indigent people in the U. S. need to be served by community health clinics-only 14 percent are currently being reached.
In Dallas, Ron Anderson and his chief policy analyst. Paul Boumbulian, looked out upon a city whose mounting public health problems were a microcosm of those of the nation. The poor and indigent were not only being injured and killed more often, they were also using emergency rooms for routine illnesses such as flu, contributing to a staggering, seemingly unstoppable burden that grew by an average of 25,000 new visits per year at Parkland alone.
In 1986, Anderson and Boumbulian decided to act. And they finally had the data, in particular an influential study from the national Institute of Medicine evaluating community health systems in the U. S. The National Rural Health Association, meanwhile, had already taken the plunge, setting up modified COPC programs, now in evaluation stage, in 13 rural counties around the country on a $1.2 million grant. But Anderson and Boumbulian had in mind a much more comprehensive plan, one specifically focused on urban areas. When, in 1987, Dallas County commissioners looked at Anderson’s proposal and voted to make COPC its public health care model, Dallas became the first major city in the U. S. to incorporate the WHO global strategy of making health an attainable human right, regardless of economic status, by the end of the century.
But COPCs in Dallas didn’t really go operational until 1989. the year that a measles epidemic struck 2,500 victims and killed 12. As i( turned out, treating the victims cost about $3.5 million at various Dallas hospitals. A Parkland study later showed that had an extra 10,000 preventative immunizations been given in time to children in high-risk areas, the total cost would have been under $200,000-a savings of almost 25:1, personal suffering and death not included.

YOU DON’T JUST BUILD A CLINIC and assume the people will come. You have to go out and find them. Social workers, doctors and nurses from the COPCs make continual visits to schools, churches, civic groups and apartment complexes in their communities. One aim is to keep epidemics like measles from turning killer again. Since 1990, 14, 000 inoculations for measles have been administered through the COPCs, and 14, 355 through separate city and county health services, but it’s only a start. The overall preschool immunization rale in the city of Dallas for common childhood diseases-mumps, measles and rubella-is only 29 percent (39 percent in the county). In comparison, a far poorer city, El Paso, has a 42 percent rate, and a far poorer country, Nigeria, has immunized 65 percent of its children.
But diseases don’t always come in epidemics-many of the worst are here year-round. Thus, another motive of operations that extend beyond the individual COPC clinics is to try to intervene in ongoing, city wide patterns of sickness.
Of all the outreach programs, the most extensive are aimed at finding and treating STDs-sexually transmitted diseases- which are particularly rampant among drug users and prostitutes. An $856, 000 HIV and AIDS prevention program offers testing and treatment through COPC centers. A separate county health department intervention project augments the HIV program by aggressively finding high-risk carriers, especially drug users and prostitutes.
Dr. Durado Brooks, a 35-year-old African-American internist who once served as administrative intern for David Smith, has now had to tell five patients they’ve tested HIV positive, and he thinks those are only the first of "tremendous numbers" yet to come. One of the toughest sessions was with a 25-year-old father of two, a happy, seemingly healthy man with a good job at a restaurant. He had come in complaining of a simple "thrash"-a sore throat. But since COPC visits are viewed as a way to keep tabs on everything in a patient’s life-part of the "family doctor" approach-Brooks decided to order a blood test, too. It bore the worst of news. "He broke down and cried," Brooks recalled. "Then he went into tremendous denial. He wanted a new test every time he came in," But now the man is being treated, and so are 98 percent of the STD carriers who have been identified so far in the COPC intervention program. It was rough telling all of them they were sick, but not as rough as plotting the epidemiologic curves of what would happen to the community if they were left unfound and unchecked.
It always gets back to that-prevention. Half of Brooks’ dozen or so patients a day are afflicted with maladies that shouldn’t even be there. "Every other week someone walks in with chest pains who’s had diabetes or hypertension for a long time and was never treated," he says. "I see people go blind or near-blind from diabetes complications. It’s a tragedy." Or an outrage. Or maybe something even more troubling. In a bold article in the November 1991 issue of the influential Journal of the American Medical Association, Brooks argued that the crisis in health care, which is essentially a crisis of the poor, is most of all a crisis in race. He titled his article "Medical Apartheid: An American Perspective."
Drawing a "startling" analogy between the effects of South African apartheid on the black population and the effects of "functional apartheid" in the United States on its black and brown citizens, Brooks traced a bleak portrait of high infant mortality and excessive overall suffering among the poor. Since blacks and browns make up disproportionate numbers of the poor in South Africa and the U. S., neither of which have national health care plans, a system that ignores the poor also disproportionately affects minorities. The situation is especially true in Dallas, where blacks, browns and Asians make up about 80 percent of those living below the federal poverty line. Brooks concluded, among other things, that "U. S. blacks die at much higher rates than whites from preventable diseases. "
The article created considerable controversy, both in Dallas and nationally. But it didn’t get Brooks in trouble with his bosses. Both Ron Anderson and David Smith were listed as co-authors.
But Smith wasn’t going to be his boss for long. In February 1992, the architect of the Dallas COPC system was named commissioner of the Texas Department of Health. Anderson, chairman of the commission overseeing the department. had provided the key recommendation. But Texas’ gain was Parkland’s loss, twice-over. Smith’s wife, Donna, who had become director of Park-land’s homeless program, also resigned to move to Austin. Anderson considers the departures "bittersweet, " but he knows there’s a payoff. With Smith installed as head of the entire state’s health program, it’s a sure bet that Dallas-style COPC clinics will be springing up from the rural counties of the Panhandle to the ghettos of Houston.

THE SALV1DAR CHILDREN’S HEALTH Center, an unassuming prefab on No-mas Street in the West Dallas barrio, is so full there’s only standing room. Hispanic and black mothers sit waiting their turns, holding their babies and watching Joan Lunden anchor canned health reports on a TV supplied by Whittle Communications, which markets its services in doctors’ waiting rooms around the country. But the viewing audience here is different. In this room, a new generation is being brought into the loop of health. A "right, " Ron Anderson calls it. Like life, liberty and the pursuit of happiness.
Dr. Mary Beck Tait, a 30-year-old pediatrician who came here from a public health position in Arkansas, is the only staff physician, but she’s backed up by two nurse practitioners. Tail spends most of her time guiding babies along a prescribed checkup path until they’re 12 years old and shift over to the West Dallas Clinic. It’s not cutting-edge medicine. This morning she checks 4-month-old Pedro, who was born a preemie but is now doing fine, except for the needle Tait has to stick in his pudgy thighs for a scheduled inoculation. Last time in, Pedro had an ear infection, but Tait spotted it and treated it before it took a turn for the worse. He may need tubes. If so, Tait will refer him to Children’s Medical Center or Parkland.
Tony, another 4-month-old, also has ear troubles. His mother, a 34-year-old who moved to Dallas from San Luis Potosi 17 years ago, had been giving him some medicine from a private doctor she went to before she found out she could use the clinic. Tait decides the infection is healed enough not to need a new prescription, but tells the mother to return in a week. Then Tony gets the needle. Tough kid-cries only a little.
It goes on all morning. Nothing fancy. Among those who come, though, is 21-year-old Laura, with her third child, also named Laura, for a four-month checkup. Laura the mother seems especially at ease in the clinic, able to describe for Tait what kind of formula she’s using and her baby’s progress in rolling over and holding her head up. Little Laura’s 2-year-old sister, Marie, slips out of the examining room to look at the other children down the hall. Marie has been treated at Saldivar since birth, too. So has her older sister, now 4, and so has Laura, the mother. And they had all been born at Parkland. And they were all healthy. No rocket science at all. Even Ron Anderson would tell you that. "People say what we’re doing is novel," he laughs one morning in his office, trying to figure out how to replace David Smith and keep the revolution moving. "But what’s really so novel about it?"