BOISE, Idaho -- When you drive past Saint Alphonsus Regional Medical Center, you drive through a Boise cityscape alive with cars, people, a gas station, hotel and a busy interstate.

Flip back to 1971, though, and you can hear the silence.

"There were horses grazing where we are now," said Sister Patricia Mulvaney, once the chief executive officer at Saint Al's, sitting in her office in a new section of the hospital.

The 80-year-old Mulvaney has been at Saint Al's off and on for nearly a quarter of a century.

Mulvaney and three other sisters find themselves among the last of their breed in a country divided over health care reform.

Health insurance should be within reach of everyone, said Sister Beth Mulvaney, Sister Patricia's sibling. "It's a social justice issue," Sister Beth said.

In the meantime there are plenty of sick people who need simple things, like a listening ear, or a prayer, or even a waste basket emptied in their rooms.

"The core of why we are here continues -- providing the best possible care we can to those in need," Sister Beth said.

The four nuns, all members of Sisters of the Holy Cross, a Catholic congregation based in Notre Dame, Ind., are the only nuns left at Saint Al's, which was founded by Holy Cross nuns in 1894. The remaining nuns range in age from 60 to 80 and between them have decades of Saint Al's history in their heads. They have no plans to retire.

The nuns' fingerprints are everywhere. They organized a program to sit with patients who otherwise would die alone. They perform special ceremonies to bless everything from new equipment and buildings to people, including the new president, Sally Jeffcoat.

Above all, they listen -- a skill in danger of being lost in our hectic society.

The four are not only the last at Saint Al's. They also are among the last U.S. nuns from the Sisters of the Holy Cross congregation to work in health care.

Nationwide, there are just 35 or so left, compared to 165 about 50 years ago, said Amy Smessaert, spokeswoman for the congregation.

Declining numbers mirror a national trend within the Catholic church. "I personally see it as changes in our social values," Sister Alice Mary Quintana said.

The three words -- life-long commitment -- may put people off, she said. "You don't see that in many of our professions, or even in marriage." Pictures on a wall show a new, nine-story tower at Saint Al's, with nuns from Sisters of the Holy Cross dressed in habits that expose only their faces and hands. They stand together in a portrait of graduates from a nursing school run by Saint Al's.

Other black and white photographs show nurses bent over beds with patients. No IV polls, no wires snake into the immodest hospital gowns patients wear today.

The hospital long since has gone high-tech to meet community needs, and through a merger has become part of the massive Trinity Health system. The nuns have stopped wearing habits and go with business attire instead.

Sister Patricia and her fellow sisters are not in the hospital business for the money. The four nuns at Saint Al's live by vows of chastity, obedience and poverty, just like the nuns in the grainy photographs of a bygone era.

Their housing, their cars, even the clothes on their backs belong to the Holy Cross congregation.

If anyone wanted the clothes, that is. "The suit I own I don't think anybody else would want to wear," joked Sister Alice Mary, faith community nursing manager at Saint Al's.

"I had a hard time adjusting to the wealth and the technology of the hospital, and the money that it costs to run it, but yet again to know that the outcomes are more beneficial than the cost if it is helping people," Sister Alice Mary said.

It is the job of Sister Mary Louise Deroin, who grew up in the Eagle, Idaho, foothills, to work with visitors in the waiting room of the intensive care unit, where the sickest patients receive treatment. She keeps track of who goes in and out and helps families during what often is one of the hardest times of their lives.

The unit gets its share of patients badly injured in car crashes or other accidents. Pain and fear often drive people to examine their spiritual beliefs, Sister Deroin said.

Her work is to "help them spiritually and give them some hope," she said. "Sometimes, they are suffering so much I cry right along with them."