The more I look at the circumstances that lead up to the criminal prosecution of a nurse in Texas for informing the State Medical Board of her concerns with a local physician, the more I wind up wondering just how things wound up where they are. It’s easy – and far from inaccurate – to view this as a case of the good ol’ boy network gone bad, or as an example of a quack doctor twisting the system to turn the accusers into the accused. The more I think about it, though, the more I’m starting to think that we’ve really been looking at part of the picture. We’ve been missing something that’s probably just as important – the role played by the totally screwed up medical care delivery system in this country.

Let’s start by taking another look at Dr. Rolando Arafiles. He graduated from medical school in the Phillipines in 1977. In 1994, he did an internship at Harbor Hospital in Baltimore. Two years later, he finished a residency in Family Medicine at SUNY Buffalo – but I can find no indication that he has ever been board certified in FP or any other specialty. In 2007, the Texas Medical Board restricted him from supervising physician’s assistants because he had failed to properly supervise (pdf) a PA at a weight-loss clinic he worked for, and had failed to ensure that the clinic protocols met standards of care.

At the trial yesterday, Arafiles reportedly had difficulty even defining “standard of care”. He said that diabetics heal as easily as anyone else. He was questioned about a number of medical errors he’s made, and he explained that contrary to reports, he had not in fact intentionally sewn part of a suture kit to a patients finger, but had instead done so accidentally. According to the hospital administrator, Arafiles has been reprimanded for mistakes a number of times since he was hired in 2008, which was confirmed by a surprise state inspection.

On top of all that, Dr. Arafiles does not seem to have ever seen a non-traditional remedy that he didn’t like. He’s been selling alkalized water and colloidal silver on his website. He testified yesterday that he – and his buddy the sheriff – have been selling the Chopra Center-endorsed supplement beverage Zrii – a 25 ounce energy drink that seems to mostly consist of grape juice, and which retails on Amazon at a little over $50 per bottle. According to woo-megasite educate-yourself.org, Arafiles was offering IV Hydrogen Peroxide and Bioluminescence Therapy in 2002. More recently – as in Christmas, 2009 – Arafiles posted something on the “no-forced-vaccination” Yahoo! group asking when he would receive materials for a homeopathy class he was interested in.

At this point, the picture is fairly clear. Arafiles looks to be a minimally qualified medical doctor, with conventional clinical skills that are, at best, barely adequate. He also has an enormous interest in non-conventional therapies. This does not surprise me. It’s easy to become an expert in a field that doesn’t really exist.

With that picture of Arafiles in mind, let’s look at Winkler County, Texas.

As of the 2000 census, the county had a population of under 8,000. Only 60% of the adults in the county had finished high school; only one in ten had finished a Bachelor’s degree. The median family income was about $34,000 (well under the national average), and the median home price was slightly under $30,000. The major highways are all State roads – not US highways, and not Interstates.

In a word, rural.

And that brings us to the health care delivery problem.

In an ideal world, you want to have extremely competent and extremely qualified primary care doctors working in rural areas. When specialists are hard to get to, when there’s no teaching hospital anywhere nearby, when trauma patients need to be airlifted to distant trauma centers (preferably after being stabilized locally), and when you have a very small number of doctors out there, you want to be damn sure that they’re all very good at what they do.

In the United States, what you get is what you can pay for. A county with a tax base like Winkler County’s is not going to be able to pay much, and the area doesn’t have all that many features that would make up for low pay. That’s why, as the hospital administrator admitted to the New York Times, it’s hard for them to attract good physicians. So they take what they could get, and what they could get was Arafiles.

So now you have Dr. Arafiles, his substandard clinical skills, and his snake oil. He’s in an environment where 40% of the adults don’t have a high school education, and 90% don’t have a college degree. He’s in a place where he can be a big fish – play golf with the sheriff, appear on local cable programs – and where many people simply don’t have the education needed to easily detect the difference between real medicine and “alternative therapies”.

Fortunately for Winkler County, they had good nurses. People who had been in the area, and at the hospital, for a very long time. People who know the community, care about the community, and are willing to do what they think is needed to ensure the welfare of their patients.

Unfortunately for Winkler County, they’ve got the doctor’s business partner/golfing buddy the sheriff, his pal the prosecutor, and the rest of the local good ol’ boy network. So now they’ve got two fewer good nurses, and they’ve still got Dr. Arafiles practicing what he calls medicine.