CONDITION: CRITICAL : County Clinics Stretched to Their Limits by Sharp Rise in Need and Shortage of Workers, Money and Space

As usual they began arriving before the doors opened.

The women held infants. The toddlers held toys. And inside the tiny public health clinic, the nurses held their breath.

By 8 a.m., the activity and noise in the North Hollywood Health Center waiting room were reaching a crescendo. Seats were claimed quickly beneath the pictures of a blue Smurf and other cartoon characters and health posters that graced the walls.

Yet Joh-nee Collins, the clinic’s nursing director, was unimpressed by the size of the crowd. “Most of the time in the lobby, you can’t walk around,” she said.

Crowds in Parking Lot

To Collins and other health center staff members, the place isn’t crowded until people are sitting on the floor, standing in the aisles or spilling out the back door into the parking lot. It isn’t cluttered until filing cabinets are jammed and medical records in cardboard boxes are stuffed under desks, into aisles and even in the men’s and women’s restrooms.

By any reasonable definition, the North Hollywood clinic and others that make up the county’s primary public health care network in the San Fernando and Santa Clarita valleys are vastly overcrowded. County health officials readily acknowledge that the eight Valley clinics are also understaffed, under-funded and lack adequate facilities to provide the best of care to the poverty-stricken and others who seek their services.

In fact, a private study delivered to the Board of Supervisors Thursday concluded that all of the county’s hospitals and clinics are so poorly funded and staffed that the quality of care is “unacceptable by any standards.” The report, prepared for the Legal Aid Foundation of Los Angeles, was based partly on interviews with more than 50 doctors, nurses and health-care workers employed by the county.

“We’re doing the impossible with the inadequate,” said Mary Lopez, a nursing supervisor at the North Hollywood facility.

At the heart of the Valley clinics’ troubles is their rising popularity among patients, which a recent county Department of Health Services report characterized as “startling.” During the five-year period between July, 1981, and June, 1986, the number of patients visiting the eight Valley clinics increased 54%, from 143,531 clients to 221,564.

The busiest clinic is in San Fernando’s barrio. During the 1984-85 fiscal year, 49,768 people passed through the doors of the brown stucco clinic. The next year, 64,801 sought treatment--a 30% increase. Following close behind as the second-most popular center is the county’s clinic in Canoga Park, where 48,657 people showed up during the same period, a 51% increase.

Staff Remains Unchanged

Yet facilities have not expanded to meet the growth in clientele. And staff size remains about the same as it was 20 years ago, say county health officials, who recall the centers back then as “sleepy places.”

Consequently, physicians sometimes must rush through examinations, ignoring county health guidelines for patient-doctor ratios. This is especially true during prenatal sessions because the number of pregnant women seeking care has increased dramatically in recent years.

Many pregnant women are turned away. At least half of those who call the Van Nuys and Canoga Park clinics for first-time appointments cannot obtain them. And in Van Nuys, the demand for routine checkups for infants has been so great that the clinic now will see only babies born in county hospitals.

Dr. Dorris Harris, chief physician for the Valley’s health clinics, knows what the panacea for the clinics is: more money. “The bottom line is we have more patients coming in. We need larger, better facilities and more staff.”

But county health officials are exploring whether the Valley clinics’ resources can be stretched more to save money. Faced with a potential $170-million deficit in the county budget, county Health Director Robert Gates has proposed consolidating three of the clinics--Pacoima, Van Nuys and San Fernando--and shutting the Burbank clinic.

The threatened action, however, may not occur. Los Angeles County Supervisors Michael D. Antonovich and Deane Dana have pledged to preserve the current level of care in the health clinics, making it unlikely the proposal will win the votes needed on the Board of Supervisors.

Nonetheless, the county is continuing its study of a merger of the clinics and whether such an action would erode the quality of health care in the Valley. A state-mandated hearing on the proposed cuts and merger will be held in mid-July.

Valley health officials aren’t expecting miracles from the county budget process this summer, but they hope to lay claim to the former Mid-Valley Hospital in Van Nuys. Harris proposes moving the Van Nuys clinic into one of the hospital’s buildings to ease the overcrowding.

County officials decided years ago to sell Mid-Valley Hospital after its replacement, Olive View Hospital in Sylmar, opened. With Olive View now open, however, the officials appear less certain about their plans. Health officials say a decision is imminent on whether the Van Nuys clinic will be allowed to move into the Mid-Valley facilities.

The problem of overcrowding in San Fernando Valley health centers is compounded by the absence of a comprehensive health center where medical tests, treatment and patients with more serious health problems can go, thereby helping to absorb the patient overflow from area clinics.

Focus on Olive View

Valley health officials suggest that the area never got a comprehensive center because money was devoted to rebuilding Olive View, which was destroyed in the 1971 earthquake.

“Most of the interest in the Valley was focused on Olive View,” Harris said.

Meanwhile, as the budget debate brews, the Valley clinics’ unattended ailments worsen.

Two- and three-hour waits by patients are common. The centers are noisy, the nerves of staff on edge and halls and rooms are cluttered with children’s toys. Clinics cannot afford full-time janitors, and staff members say soiled diapers and discarded trash sometimes litter the floors.

For patients, the delay is often the most difficult to endure. “It drives the kids crazy when they have to wait here,” said Martha Diaz, 21, who was at the North Hollywood clinic with her young son. “That’s what I don’t like. You have to wait a lot. When I was pregnant, I once had to wait five hours.”

Burnout of staff members is a constant concern. On many mornings in the San Fernando clinic, a nursing supervisor places a cake and a newspaper in the kitchen to boost morale among the staff. Hundreds of blue and white coffee cups have been passed out to Valley staff members. The cups’ motto trumpets: “I Am the Best!”

Outdated Equipment

Most of the Valley clinics lack sophisticated laboratories, pharmacies and X-ray rooms. Some of the equipment is obsolete. At the Van Nuys clinic, nurses curse the centrifuge, used to separate blood. The X-ray machine in Canoga Park can scan chests, but not limbs and broken bones.

At the San Fernando clinic’s pharmacy, obtaining the most up-to-date drugs can be difficult, but complainers are reminded to count among their blessings that the clinic has a pharmacy at all.

In the Valley, analogies to Third World health care are common. Dr. Lucia Carpenter, who supervises the Van Nuys and Canoga Park clinics, said a UCLA medical student once said of the Van Nuys facility, “It’s just like clinics in Nigeria except it’s not as well equipped.”

The Los Angeles County public health clinic network was established in 1963, when the county took over complete control of public clinics from the City of Los Angeles, which abdicated its responsibility.

The centers receive most of their funding from the county, although the majority of patients must pay fees that typically range from $5 to $25. Anyone is eligible to receive health care from the centers, but they attract mostly low-income residents.

The centers’ role as primary health providers is a diverse one. Physicians and nurses track pregnant women and infants to make sure they stay healthy. They prescribe medicines for illnesses ranging from diabetes to heart disease. They treat venereal disease and test for tuberculosis.

Quality Patient Care

Clinic physicians and nurses who bemoan the lack of facilities, staffing and funding say the patients are well-cared for nevertheless.

“The quality of care is excellent, absolutely excellent,” Carpenter said. “We are very up on current medications and treatment of certain diseases. We are a resource for the private sector.”

Almost all the physicians are board certified, Harris said. Many are specialists. Because the clinics are affiliated with UCLA, medical students also rotate through the centers. Some physicians take one day off a week from their private practices to work in a Valley clinic.

But the ever-increasing patient volume worries the doctors.

“It’s hard to get a good doctor-patient relationship,” lamented Dr. Alvin Jackins, a Tarzana obstetrician-gynecologist who sees patients at the Van Nuys clinic once a week. “You have to work very fast. . . . We try to answer questions, but it’s difficult because of the high volume. Some of the patients have several questions they’d like answers to. We have to limit what we can answer.”

Patients who were interviewed at several clinics say they are satisfied with the quality of care. Compared to other institutions they have visited, the clinics come out on top, they say.

“I’ve been coming for seven years. I like it,” said Leticia Cova, who was conferring with a nurse practitioner at the San Fernando clinic about her 7-year-old daughter’s weight problem. “They have really good doctors who are concerned. You can’t beat the price.”

County health officials say a growing cadre of impoverished families, many of them immigrants from Mexico and Central America, have boosted the patient rolls at the Valley clinics.

Not Just the Poor

The clinics, however, do not function merely as health centers for the needy. People of all economic means are treated for communicable diseases and take advantage of free immunizations for children.

In fact, the centers’ increased popularity was bolstered in part by a 1985 government directive requiring children entering county schools to be tested for tuberculosis. Card tables were set up on the lawn at some clinics to handle the flood of new clients.

Against that backdrop, the personnel shortage has become a significant problem. When a staff member calls in sick at a health center, it sometimes triggers panic. Telephones ring throughout the clinic network as supervisors seek to borrow a doctor, nurse or attendant.

“This whole thing is a chessboard. Every morning we ask, ‘Where do we put our scarce resources?’ ” said Dr. Lionel Cone, who oversees the county’s health centers in Valencia, San Fernando, Pacoima and the Antelope Valley.

Without Extra Hands

On a recent day, Millie Holland, nursing supervisor for Cone’s district, was struggling to answer that question. Earlier, she had dispatched a nurse’s assistant from the San Fernando clinic to fill a vacancy at a family-planning session in Valencia. But the Pacoima clinic called, saying a staff member was out sick and they needed an extra hand.

Holland reviewed the options and then called the Pacoima clinic with her decision: “I can’t give you anyone.”

Some nurses confide that they are scared about the potential health consequences such bare-bones staffing might have.

That’s because on busy days, public health nurses are sometimes asked to forgo their duties in the field to pitch in at the clinics.

Public health nurses usually spend most of their time in the community trying to prevent outbreaks of such communicable diseases as tuberculosis, hepatitis A and salmonella. In home visits, they make sure patients--particularly those with high-risk occupations like restaurant, nursing-home and day-care workers--are taking their medicines and staying off their jobs.

But taking public health nurses off the streets even part of the time “is putting the community at risk,” said Ruth Woods, the district nursing director for Van Nuys and Canoga Park.

There’s No Room to Work

County health officials note that proposals to expand the clinics’ staff are pointless when there is no room for them to work in the centers. The Valley has some of the county’s smallest and oldest health clinics, with an average age of 32 years.

The San Fernando facility holds the distinction of being the county’s oldest--an outdoor plaque tells of 61 years of service. The most recent one to be built in the area is the 15-year-old Valencia center. For years, the clinics in North Hollywood, Canoga Park and San Fernando have lingered on the county’s priority list of centers deserving new buildings.

“One of the major problems is just the lack of adequate financing to construct new facilities,” said Larry Roberts, deputy director of the county’s health center operations.

At Canoga Park, the physicians share an examining room with the part-time janitor. When the janitor needs a mop, he has to knock and wait for permission to enter.

At some clinics, babies are weighed and their vital signs examined in the waiting rooms. It is common for a pregnant woman to be interviewed about intimate physical and sexual details in a small room shared with two or three other female patients.

In the San Fernando clinic, fire marshals had warned health officials that there were too many people standing in the halls before money was found to expand the waiting room.

“When you’ve started with very, very small clinics, it gets to be almost like a zoo, “ Harris said.

In Every Nook and Cranny

The storage of medical records and other documents aggravates the space shortage. To hear officials talk of their growing paper stockpiles conjures images of horror films where the monster, despite the best effort of the good guys, cannot be vanquished.

“We fit them in every nook and cranny,” said Carmen Cordero, the business manager of the North Hollywood clinic.

Desks have been pushed against the wall in the North Hollywood business office to create more space for encroaching files. Two clerks have chairs but no desks because there is no more room in the office. A bumper sticker on the wall reads: “This is not Burger King, you can’t have it your way.”

The makeshift repository for excess patient charts in the Canoga Park clinic is the women’s restroom. Immunization records are stored in the men’s bathroom.

While waiting for a solution, North Hollywood and San Fernando clinic administrators have proposed acquiring trailers for offices to free space for examining rooms in the clinics.

How do patients and clinic workers manage to survive the stress, overcrowding and inconveniences? By relying upon one another and a sense of community. Their needs transcend medicine and the clinics have become more than a place where pills, bandages and advice are dispensed.

They Care, Reach Out

“The people in those clinics really care,” said Becky Gaba of MEND, or Meet Each Need with Dignity, a private social service organization in Pacoima. “They are doing a wonderful job. They really reach out in the community.”

When a baby has no crib or a family needs food or a space heater, nurses will take up the cause themselves or call MEND. Christmas parties are thrown for the children who are clinic patients. In San Fernando, Holland often arrives at the clinic at dawn so she can attend community meetings later.

Perhaps the best symbol of the commitment and dedication of the clinics’ staff is a homely little black statue that sits in the cluttered office of Dr. Angela Murphy, chief physician at the North Hollywood clinic.

On her walls are a world map highlighting risk areas for travelers’ diarrhea, snapshots and a diagram on skin rashes. On her desk is an Ecuadorean pencil holder and nearby, a supply of Irish tea leaves. But the black statue of a woman carrying a jug on her head stands out in the clutter.

Murphy has bought and sold the statue to herself three times. Twice a year, the staff brings in junk to sell to one another at an auction. The money raised is used to help families who don’t have bus or cab fare to get to Olive View Hospital when their medical needs are too serious to be treated at the clinic.

No one ever bids on the statue, so Murphy keeps buying it back. “I tell people it’s an artifact,” Murphy said. “There really aren’t many ways we can get money.”