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When their only hospital closed, fears of more deaths took over. What we found in the data.

Located right off of interstate 99, the Madera County Flea Market is a place to find all manner of used gear, toys, and fresh produce.
Kerry Klein
Located right off of interstate 99, the Madera County Flea Market is a place to find all manner of used gear, toys, and fresh produce.

Madera County residents have now gone 18 months without a hospital. In that time, the consequences on public health haven’t been so clear. We investigate just how much health outcomes have changed.

MADERA, Calif. – More than a year and a half since Madera Community Hospital closed, nearly everyone who depended on it has a reason why they want to see it back open.

That includes those gathered at the twice-weekly Madera Flea Market on the north edge of Madera, the largest city in the county where the hospital also used to be located.

The flea market – remate, as it’s called in Spanish – is just 10 miles up the highway.

Both are community institutions. At the flea market, crowds gather Wednesday and Sunday mornings to buy used lawn equipment, secondhand clothes, and all manner of kids’ toys. And in a county where incomes are lower than the state average, it’s also a place for some to make extra cash.

Unlike the flea market, however, the hospital shuttered in December 2022 and has been litigated in bankruptcy court for months.

“All of the community here in Madera depended on the hospital,” said Julia Mendivil, carrying a brightly colored rocking horse she just bought for her grandchildren. “Especially those who don’t have a car to travel elsewhere, it’s difficult for them.”

Jesus Ramos, who can’t drive, said it’s terrifying to be so far from a hospital. He’s scared he won’t be able to find a ride in an emergency.

Angel Garcia, who was handing out pamphlets promoting the Jehovah’s Witness faith, said he knows firsthand that every moment in a crisis matters.

“With three heart attacks that I've had in the past, I've gone to hospitals nearby, but now there's none,” he said.

A fresh coat of bright white paint is part of the makeover Madera Community Hospital has been getting since a bankruptcy judge approved of a purchase from a new owner earlier this year.
Kerry Klein
A fresh coat of bright white paint is part of the makeover Madera Community Hospital has been getting since a bankruptcy judge approved of a purchase from a new owner earlier this year.

Linette Lomeli, Executive Director of the Madera Coalition for Community Justice, a non-profit that focuses on helping residents meet basic needs like food and healthcare, said plainly it has been “a very scary time for the entire county.”

Many residents, she said, like farmworkers without cars or paid sick leave from work, were forced to choose between an income and traveling out of county for care – while others were simply left in confusion about how to set up a doctor’s appointment and where to seek out routine x-rays and blood tests.

As a result, she said, many residents simply put off care.

Linette Lomeli, pictured here at the Madera County Flea Market, is executive director of the Madera Coalition for Community Justice.
Kerry Klein
Linette Lomeli, pictured here at the Madera County Flea Market, is executive director of the Madera Coalition for Community Justice.

In an already vulnerable county, where nearly a fifth of residents have asthma, hundreds succumb each year to chronic disease, and more than half rely on the government-sponsored safety-net health insurance known as Medi-Cal, one might expect the hospital’s closure to have kicked off a deadly public health crisis.

But state data is helping paint a better picture of what happened in the weeks and months – and year – since the hospital closed. Though only so many conclusions can be drawn from just one year of data, the numbers suggest that what some had gravely feared has not come to pass on a large scale.

Officials see an example of a ‘success story’

In the year after the hospital closed, fewer Madera County residents died than the year before. And among the most common causes of death, only a handful appeared to cause an uptick in deaths post closure.

Dan Lynch, director of Central California Emergency Medical Services, has an idea of why this is. He partly attributes it to coordination among healthcare providers in the region.

Within days of closing, nearby emergency departments – already running at capacity due to COVID-19 and other respiratory illnesses – made space for an influx of patients. Even Valley Children’s, the largest provider of pediatric health services in central California, played a role in helping stabilize adult patients when needed.

Ambulances from outside of the Madera hospital’s area also responded to calls in Madera County. Ambulances are privately owned and typically operate only in a specific coverage area. Meanwhile, Camarena Health, a non-profit that runs a network of clinics throughout Madera County, hired doctors and nurses laid off by the hospital and took on their patients.

“I think it's a success story that we've been able to mitigate the damage done by Madera Community Hospital closing,” Lynch said.

A hospital’s value

According to state data, the hospital delivered between 700 and 800 babies and performed upwards of 1,700 outpatient surgeries each year. In early 2020, the hospital was also the first in the San Joaquin Valleyto take on a COVID-positive patient.

Lynch’s assessment on why the region may have avoided bigger losses begs a blunt question: If healthcare can continue running without a hospital, does this mean the hospital doesn’t matter?

“I think completely the opposite,” said Dr. Simon Paul, Madera County’s Health Officer.

In 2020, the year the pandemic took over, deaths among county residents due to COVID soared before they began to fall back down in 2022. Then the hospital closed in December of that year. Paul says one likely reason data shows fewer people died after the hospital closed is because COVID-related deaths were already dropping as is.

Because of these overlapping trends, Paul says it’s difficult to truly determine how many fatalities can be attributed directly to the closure of the hospital.

He acknowledges that some Madera residents likely did die as a result of the closure. After all, their nearest emergency room disappeared. But with more than 1,000 total deaths each year, it’s too difficult to tell just how many were in that situation.

“That can be very true and it is horrible but it's not going to show up” in the data, Paul said.

Dr. Simon Paul is Health Officer for Madera County.
Kerry Klein
Dr. Simon Paul is Health Officer for Madera County.

Paul also notes a hospital’s value isn’t solely based on treating life-or-death emergencies. People sought care at the facility for chemotherapy, dialysis, and chronic disease management. The hospital also treated more than 50,000 patients each year in its rural primary care clinics.

And so, Paul says, the measure of a hospital may be something deeper: how it can impact the quality of life of its patients — and what can happen when people put off care.

Those who delay, Paul said, “are not going to die in the next six months because of this delay in care, but they are going to have complications from diabetes a couple of years from now that maybe could have been avoided.”

Madera Community Hospital is slated to reopen later this year. Like many residents, Lomeli, of the Madera Coalition, is eager for its doors to be back open.

“I don't think that there's quite going to be that feeling of normalcy or stability in our healthcare here locally until our hospital is reopened,” she said.

But the hospital in its former iteration wasn’t perfect. As the facility’s new owners turn the lights back on, she hopes they improve the quality of care too.

“We want the hospital to reopen, but we want our community to have access to better healthcare,” she said. One thing she wants to see is better emergency care and more cultural competency for non-English-speaking patients.

Some conditions saw spikes in deaths after hospital closure

In any normal year, Alzheimer’s, diabetes, cancers, respiratory infections and an array of heart diseases are the leading causes of deaths in Madera County. The list doesn’t change much from year to year, except that COVID appeared at or near the top from 2020 to 2022.

Of those most common conditions, only a handful appear to have resulted in a rise in fatalities since the hospital closed.

But one condition stood out for how it changed year by year: liver cancer, which more than doubled from 12 to 29 deaths before and after the hospital closed.

Dr. Marina Roytman, a liver specialist at Community Regional Medical Center and faculty member at the UCSF Fresno School of Medicine, has directly observed negative effects among patients who have put off preventive liver care without the Madera hospital.

“One of the first things that goes is that routine screening or routine surveillance,” she said. “And as the result of it, they eventually show up in our emergency room with cancers that I've only seen described in textbooks.”

Another condition that resulted in more deaths after the hospital closed is atherosclerotic cardiovascular disease, which causes hardening of the arteries.

Madera cardiologist Dr. Mohammad Ashraf has observed this in his patients. But Ashraf says says he’s also seen an uptick in deaths due to heart attacks — known as myocardial infarctions — including in some patients who he says succumbed because they couldn’t reach a hospital in time.

However, if the state figures are to be believed, heart attacks killed fewer patients after the hospital closed than before.

“I was very surprised when I saw the data,” he said.

Ashraf says some inconsistencies he sees in the data could be due to differences in how providers and coroners fill out death certificates. But he also suggests the data could be wrong, or at the very least incomplete.

In a statement, a representative of the California Department of Public Health responded to say that the only data that may be missing from the data that KVPR obtained from the Cal-ViDa database would be those Madera County residents who died out of state. However, the representative did point out that the database provides only the primary underlying cause of death, even if more than one condition was present at the time.

“Consequently, while underlying cause of death provides a convenient comparison between cause of death categories, it may result in the cause of death to not account [for] all conditions contributing to the death,” the statement reads.

However, Ashraf’s concerns seem to reach more broadly than the specific data used in this story, which correlate with those also used by local public health officials.,

Despite the organized efforts to continue healthcare in some form after the closure of Madera Community Hospital, Ashraf also objects to any suggestion that a hospital’s primary role in a community isn’t to save lives.

“Close down the hospitals and people will be safe? It doesn’t make sense,” he said.

Kerry Klein is an award-winning reporter whose coverage of public health, air pollution, drinking water access and wildfires in the San Joaquin Valley has been featured on NPR, KQED, Science Friday and Kaiser Health News. Her work has earned numerous regional Edward R. Murrow and Golden Mike Awards and has been recognized by the Association of Health Care Journalists and Society of Environmental Journalists. Her podcast Escape From Mammoth Pool was named a podcast “listeners couldn’t get enough of in 2021” by the radio aggregator NPR One.