Poverty, health struggles in scenic Mendocino

As the last customers trickled out of Costco on a recent Saturday evening, a young couple steered their Honda CR-V into the parking lot.

The long 70 miles from Mendocino County had been rife with roadblocks, and Irma Barragan and Saul Estrada were frustrated to see that they had arrived just as the Santa Rosa warehouse closed its doors.

The drives are exhausting, but Barragan, a 33-year-old housekeeper, and her husband, a cable company worker, see them as the only way to keep their four children healthy on their combined income of $36,000. Even with the price of gas factored in, groceries in Santa Rosa cost almost $150 less than the equivalent groceries purchased in Mendocino County, Barragan said.

"For me, it's cheaper to take a ride to Santa Rosa and to spend the money," she said. "It's easier to take a trip every three weeks and just hit Costco and come back home."

Unhealthy living

Outsiders may see Mendocino County as a picturesque place of redwood forests, wine and ocean views, but for locals, it is not a particularly healthy place to live. Much of its 3,500 square miles is rugged and unwalkable, leaving precious little space for outdoor exercise. Fast food outlets outnumber grocery stores. And, according to the national database County Health Rankings, its 87,000 residents have the eighth-worst chance in the state of living to age 75. In contrast, the premature death rate in neighboring Sonoma County, which includes Santa Rosa, is among the 20 lowest in the state.

"Even though we're out in this idyllic, beautiful area, there's a lack of recreational facilities and paths for walking and bicycling," said Colleen Schenck, a program administrator for Mendocino County's Health and Human Services Agency. "Because we've been an agricultural community, I think people might also assume that fresh fruits and vegetables are abundant and accessible to everyone. And they're not."

Mendocino is like many rural counties in the United States. Its residents are likely to be poorer and more dependent on low-income insurance or have no insurance at all. They tend to smoke and drink more, exercise less and worry more about food. They suffer more from chronic illnesses like heart disease, obesity and diabetes, and depression and other mental health issues.

Teaching healthy ways

A program under the new federal health insurance law, the Community Transformation Grants, is trying to ease these inequities by giving millions of dollars annually to distressed communities nationwide. The five-year grants, which started in 2011, are intended to keep residents out of the doctor's office by establishing programs to make their communities healthier places to live.

Of the $22 million California is projected to receive annually over the five-year life span of the program, about $3 million will be divided each year among Mendocino and 11 other rural counties: Calaveras, Humboldt, Imperial, Madera, Merced, Monterey, Shasta, Siskiyou, Solano, Tulare and Tuolumne.

"What we're trying to do is start at the local level and build healthy, safe communities and neighborhoods and reduce health disparities in one form or another," said Mary Pittman, president and chief executive officer of the Public Health Institute. The Oakland nonprofit and the state's Department of Public Health are administering the grant.

Mendocino County officials are receiving $240,000 annually and using it to try to ban smoking in apartments, educate residents about cutting down on sugary beverages, teach people about healthy living, and encourage children to walk to school.

So far, results are mixed. But the government says the grant will help 130 million Americans such as Barragan, whose life illustrates the anxieties widely shared in this region by those trying to survive with few resources.

"Trying to do it the healthy way," she said, "is hard."

Barragan has lived in Gualala since she was a girl, when her mother found work in the area. But she was born in Mexico and loves the food of her heritage - the oils and meats of tamales and enchiladas. Her children and her husband, also from Mexico, adore it too, so she said she used to cook "all the heavy food that you can imagine."

Changing eating habits

Then, last July, she took a cooking class at a local center. She learned about the benefits of eating more vegetables and cutting starch.

Unhealthy eating habits have visible outcomes in this county. Sixty-three percent of adults report being overweight or obese, compared with 57 percent of adults statewide, according to the 2007 California Health Interview Survey. Diabetes diagnoses rose from an estimated 4 percent in 2005 to 7 percent by 2009. Coronary heart disease is the county's leading cause of death after cancer.

Barragan says her mother and many of her relatives have high cholesterol and diabetes. So far, she, her husband, who is 35, and her four kids, ages 2 to 18, are healthy. And she wants them to stay that way.

"I don't want them to suffer like I did with food," she said.

Comparison shopping

But organic and non-organic food alike costs more in Gualala, where the three local supermarkets must pay extra to transport produce from hundreds of miles away. Barragan estimates that a local shopping trip costs nearly $500.

It's cheaper to make the winding drive south to Santa Rosa. She and her husband calculate that they typically spend about $370 per trip: gas is $50, a meal on the way is $20 and groceries are usually $300.

Usually, they get their fresh produce and meat at Costco and pick up frozen food at Trader Joe's. On a recent Saturday, however, they would have to find it all at the latter.

Barragan's 5-foot-2 frame - 20 pounds slimmer than last year - whipped through the aisles. "I can do that," she said, picking up a $1.69 pack of dried mango slices. Then she pointed to dried orange slices for $3.29. "I can't do that."

An aisle over, she picked up $1.99 boxes of low-sodium chicken broth. At Surf Supermarket in Gualala, a box costs $2.99 to $4.49.

It wasn't long before the cart was almost overflowing with food. "This," she said, "is only enough for two weeks."

A new diet

Over the past year, Barragan has swapped canola oil for olive oil, white rice for brown. She serves plenty of salad and seafood, but Mexican cuisine just once a week.

Estrada misses Mexican food, but says the kids "are learning how to eat a little better than what we ate before."

The children don't always agree. "Sometimes she makes carrot juice. I don't like it," said Valerie, 6. "It tastes like carrots."

At Trader Joe's, Barragan's 121 items totaled $190.94 after food stamps. Normally she'd go to Costco for fish and meat, but this week the missed opportunity to shop there meant she'd have to look for deals at the Gualala markets. "It's more expensive to live up there for sure," she said.

Junk food plentiful

Junk food is easy to find where Barragan lives. The county estimates that convenience stores and fast-food spots are twice as plentiful as grocery stores and farmers' markets.

The trek to Santa Rosa doesn't sound extreme to Diane Agee, chief executive officer of Redwood Coast Medical Services, which serves Sonoma and Mendocino counties. In an area where 20 percent of the population lives below the federal poverty level, many struggle to afford nutritious food, she said.

"Lots of people will take a trip once a month to Costco or something like that," she said. "If I go to the local grocery store, a bag of groceries is $60 or $70."

Steve May, who co-owns Surf Supermarket in Gualala, acknowledged that he has to raise prices slightly to cover the cost of shipping in organic goods. But, he said, consumers who shop outside Gualala don't realize that they force small stores like his to charge even more and hire fewer local workers.

"We're struggling to survive," he said. "And if our community doesn't start voting with dollars, we won't survive."

Working in exercise

Price isn't the only reason many consumers avoid May's store. Geography is another.

For the relatively little she can afford to buy from the town's two main grocers, Barragan doesn't think it's worth it to walk an hour to them and back home again - and she tries to walk as often as she can.

Walking is simply inconvenient in this vast region. In 2007, 78 percent of students surveyed in the California Health Interview Survey said they hadn't walked, biked or skated to school within the week.

For her part, Barragan keeps a pair of tennis shoes in her trunk for when she wants to walk. She dances around the house with her littlest ones. But even though her older sons enjoy wrestling, soccer and basketball in school, they're reluctant to burn a few calories by strolling around the neighborhood when the school day is over.

Under the Community Transformation Grant, county and school leaders organized a walk- and bike-to-school day to encourage students to be active. Participation last school year wasn't as widespread as organizers hoped: Just six schools of the more than 60 in the county took part.

But Rickey Gravier, 12, thinks the events will encourage more of his friends to bike. The sixth-grader pedals a mile a day to and from Round Valley Elementary and Middle School in Covelo.

"It helps for people, it helps for diabetes, and it's just really fun to do it," he said.

Policy changes

Some of the grant's goals are being met faster than others. After high school students gave a presentation on the negative health effects of soda, the Fort Bragg City Council banned diet soda from vending machines on city property. And over the past year, about 60 residents have attended community-led workshops about eating well, exercising and taking care of their diseases. These are similar to the cooking class Barragan took, but more expansive.

In addition, the county has persuaded a rental management company to ban smoking in its apartment buildings. Other deals are under way.

"The thing I'm realizing at this point is that this is a very long-term project, that nothing is happening quickly," said Schenck, the county's health and human services official. "I think there's a lot more work we need to do to get the word out."

For all the health improvements it has set out to make, the Community Transformation Grant probably won't directly change health care. An estimated 22 percent of locals, including Barragan, use Medi-Cal, and 16 percent lack insurance.

"I don't have a lot of faith it'll really get down to the sick people," said Linnea Hunter, CEO of the Mendocino Community Health Clinic, which serves 27,000 patients. "It leaves us with having to take care of these people that are a huge burden to the system with very little money."

Looking to the future

Schenck said the grant is meant to prevent problems from happening, not to treat those that exist. Once the grant ends, the community will have to figure how to implement policies or practices that will last for years and reach more than a few individuals, she said. And as the programs grow, the hope is to connect more residents with clinics and hospitals.

Deep neighbor involvement is crucial, said Jeri Bigbee, an adjunct nursing professor at UC Davis. "When a community ... owns an idea, they'll figure out how to make things continue," she said.

Barragan and Estrada's trip to Santa Rosa ended around midnight, when they finally pulled into their driveway. She comforted the sleepy children as he hauled in the groceries.

It wasn't long before Barragan was back in Santa Rosa, this time thinking about some worrying news.

She had just found out she would get a raise for her new job as a housekeeping supervisor at a hotel - so much of a raise, in fact, that she would no longer qualify for Medi-Cal or food stamps. She worried that her new income would not be enough to cover the cost of the full-time babysitter she would now need.

For the thousandth time, she wondered: How would they afford to eat?

"It'll be harder," she said. "But we have to do it."

This article originally ran in the San Francisco Chronicle on July 22, 2013.