Parents, some in their teens, some careworn and aging, come each day with freshly scrubbed children to stand in line outside the Venice Family Clinic. They are there because they have heard, on the street or from friends, about the clinica familiar, the clinic where care is free.
Often, at day's end, some of the sick are turned away. An apologetic receptionist asks that they come back tomorrow, explaining that the lines are too long, the hours too short.
Facing a steady increase in the numbers of poverty-stricken families on the Westside, the Venice Family Clinic is struggling to keep up with the demand.
Last year, it turned away more than 1,000 needy people.
And with just one primary care doctor per 10,000 residents in Venice--compared to one for every 500 residents statewide--the critical need for care among the Westside's poor is not likely to let up soon.
"Responsibility for the poor has been abandoned by the government, and we are picking it up," said Fern Seizer, director of the Venice Family Clinic. "We are attempting to meet the need, but as fast as we expand, we fill up. The crush is incredible."
Since 1983, when the state cut off health care benefits for the "working poor" and turned the responsibility over to individual counties, the Los Angeles County Department of Health Services has scrambled to find money to care for the poor.
But, county officials and poverty advocates agree, there is not enough funding to meet the need. Dozens of free clinics and reduced-cost community clinics have stepped in to fill the void.
Founded in 1970, the Venice clinic recorded about 3,000 patient visits its first year. By last year, that number had swelled to 13,163, with a 25% boost in the past two years alone.
Last fall, when the clinic moved from its headquarters on Lincoln Boulevard to a larger facility on nearby Rose Avenue, it was immediately filled to capacity, Seizer said.
"We even began opening up earlier in the morning and on Saturdays, and the people just keep streaming in," she said.
Today, the clinic has a paid staff of about 20, including a full-time physician. In addition, about 140 physicians--many of them specialists at Los Angeles's top universities and hospitals--volunteer a few days each month to handle special cases. Another 800 volunteers help with everything from fund-raising drives to scrounging donated equipment, she said.
The clinic is affiliated with the UCLA Medical School, which assigns resident physicians and nurses to train there. It also also relies upon private donations and grants, and in-kind services from St. John's Hospital and Santa Monica Hospital.
Such help "means our survival," Seizer said, since only about 3% of the clinic's patients have health insurance, and 88% have incomes below the federal poverty level. Donations from patients average about $2.40 a person.
Of the patients who visited the clinic during the past year, 69% were Latino, 24% were white and 6% were black, Seizer said. More than 60% were women, reflecting the high number of single mothers who have sought help. About 70% were from the Westside, but many, probably unaware that there were free clinics closer to them, came from as far away as the San Fernando Valley and downtown Los Angeles, she said.
Most of the clinic's patients hold jobs--often as low-paid factory workers, housecleaners and handymen.
These are "not the kind of people who are just looking for a handout," Seizer said.
'You Have to Make Choices'
But, she said, "when you have almost no money, you have to make choices: groceries or the doctor?"
Lucrecia Rosales, 23, a Guatemalan who moved to Venice four years ago, said she came to the clinic last week after her regular clinic dropped its policy of charging the poor half-price.
Though her husband supports their family of four with his job as a cook, she said, "we don't have the money to pay for a doctor. We heard about the free clinic and came right away."
Ermilinda Cash, who waited at the clinic on a recent day with two of her three children, said she has not been able to find steady work since coming to the United States six years ago from Nicaragua, where she was a nurse.
Her medical needs are mounting now that her oldest son, who is 14, has been diagnosed as suffering from cataracts. And her youngest son, who is 3, "seems to pick up every childhood sickness that comes along," she said.
"We need the clinic, even with the long lines, because in the United States it's money," she said. "Everything is money."
As a result of such poverty, Seizer said, many Westside residents suffer from chronic diseases and acute illnesses rarely seen among the middle class and wealthy.
"We have incidents of women who have never had a Pap smear," said Mandy Johnson, the clinic's program director. "By the time they get their first Pap smear, they can have very advanced cervical cancer that should never have gone that far."
In fact, some diseases become life-threatening because of the lack of medical care, Johnson said.
A man using a mop for a crutch appeared at the clinic last week, barely able to walk because of a severely swollen leg, said Mary Smith, a nurse practitioner. A virus had entered his bloodstream from an unattended cut on his foot, leaving him nearly crippled with phlebitis, she said.
Patients with such critical problems are rushed on a $30 taxi ride--paid by the clinic--to Harbor-UCLA Medical Center in Torrance, the closest free county hospital.
"We treated a man last week with chronic (high blood pressure) whose eyes were actually hemorrhaging," Johnson added.
"He was, at that advanced stage, under severe risk of stroke or heart attack. In a middle-class practice, you just don't see these kinds of things."
Seizer said many of the sick and poor who come to them say they have given up trying to get help from the county health system.
The nearest county facility, the Yvonne Braithwaite Burke Health Center in Santa Monica, is open from 8 a.m. to 5:00 p.m. weekdays, when many of the poor must work, she said. In addition, patients often must wait more than a week for an appointment, county officials say.
"Frankly, the poor are discouraged by the county system," Seizer said. "These are not people who can take executive lunches to see a doctor."
A second, perhaps more far-reaching, obstacle is the county's controversial practice of failing to inform patients that they could qualify for free care.
The practice, brought to light during legislative hearings last year, has pitted a coalition of poverty advocate groups--including the Los Angeles Legal Aid Foundation, Western Center on Law and Poverty and American Civil Liberties Union--against the county.
The groups claim that the county is not publicizing its Ability to Pay program, and instead demands fees of $20 and $30 from the poor before they can receive care.
By law, the county is required to provide free care to anyone below the poverty level. For example, a family of four making $800 a month or less, or an individual making $400 a month or less would get free care.
Melinda Bird, of the Western Center on Law and Poverty, said the coalition has found that "if anything, things have gotten worse since last year.
"The county financial workers are angry, sometimes furious, when we go into the clinics and explain the Ability to Pay program to patients who are waiting," Bird said. "At County General they have even tried to prevent us from talking to the patients."
But county officials say that since the legislative hearings they have dramatically stepped up their publicizing of the Ability to Pay program.
Frank Binch, acting deputy director of planning for the Department of Health Services, said signs explaining the free program have been installed in clinics, and financial screeners have been encouraged to inform the poor about free care.
"We are doing our darndest to get the word out," Binch said, "but anytime you're dealing with the volume of patients we do, and anytime you're dealing with language problems and people who are intimidated by government, you're going to run into problems."
Binch conceded that the county's application process can cause a patient to wait weeks before qualifying for free care, "and that frustrates a lot of people and a lot of poverty advocates." But, he said, "the only way to improve the system is with money, and money is tight."
Adding to the crush at free clinics, Seizer said, is a surge in the county's homeless population that has brought an estimated 3,500 to 5,000 of the homeless to the Westside.
In an attempt to treat the homeless, the Venice clinic in January began sending teams of nurses and doctors into the field, Seizer said.
A team travels each week to a shelter for the homeless at the Bible Tabernacle in Venice, the Salvation Army in downtown Santa Monica, the Ocean Park Community Center in Santa Monica, and a parking lot where the homeless congregate on Venice beach. The teams provide medical screening and basic treatment to anyone who is in need.
One recent evening, the team treated and interviewed more than 20 people in the basement of the Bible Tabernacle mission on Washington Way, which helps hundreds of the homeless each week.
Valerie Jones, a licensed vocational nurse from Compton, sought shelter at the Bible Tabernacle after she got involved with drugs and lost her nursing job.
Now, as she struggles to prevent her 10-month old baby, Genesis, from picking up the sicknesses she has seen in children on the street, she said, "I'm giving her a lot of vitamins, watching her all the time, and putting my faith in the Bible that I can pull out of this mess I have created."
'We Need a Job'
Calvin and Pat Gatison, who said they came to the mission after being thrown out of a South Gate motel for sneaking in their five children, said life on the streets is tough enough without worrying about health problems.
"We're glad for the food and medical care," Pat said, "but what we really need is a job so that we can help ourselves. You have to kind of go on the concept that everything will get better--something's got to break."
Mary Smith, the clinic's specialist in care for the homeless, said families on the street fall into a cycle, passing their illnesses on to others, who also cannot get adequate treatment and pass it on to still others.
"Hepatitis is always a threat, and someone who has active tuberculosis and is not being treated is continuing to expose other people to the bacteria," Smith said.
The Rev. Fred Hilst, who operates the church, said he tries to ensure that "people don't leave here until they are back on their feet, physically and spiritually."
In addition to help from the Venice clinic, he said, county workers visit the church each morning to interview the homeless and conduct examinations for diseases.
"We are so grateful for any help we can get, because we know these families do not have any way to get to a doctor or to pay him," Hilst said.
With such a strain on the Westside's health care programs, officials of the Venice Family Clinic said, it is time that the county recognize that free clinics "are a part of the system" and should be reimbursed by the county.
Dr. Mayer Davidson, director of the diabetes program at Cedars-Sinai Medical Center and a founder of the Venice clinic, said the county "should acknowledge that we are doing part of their job for them so that we don't have to fight for survival year in and year out. Essentially the county is getting a free ride from us."
In fact, a county- and state-funded study, which should be completed by late August, is expected to show how much help the county is getting from 11 community clinics who care for the poor.
The big question, Binch said, is whether the clinics are shouldering a significant portion of the county's responsibilities.
"Sentiments (among county officials) vary quite a bit because nobody knows how much help the clinics are really providing," Binch said.
"But there are those who believe that clinics are making a big contribution, and they think we should help them out as much as possible."