The Toughest Job in L.A. Health Care
Gilbert Saldate’s been stood up, blown off and shooed away. He’s heard every excuse, every lament, from people whose life contents are dumped in shopping carts or strewn about the pavement. “That’s their right,” he says--no offense taken, no judgment implied.
Yet even he was growing exasperated with the couple living under the Hollywood Freeway near downtown Los Angeles. For three years, on and off, he’d been urging them to get drug treatment, apply for assistance, do something.
He’d stuck up for the woman before a judge, only to have her ditch the court-ordered detox program. He’d arranged for doctors to amputate the man’s gangrenous left leg--the only treatment left for a broken limb with a 9-year-old sore.
Still, Saldate couldn’t pry Leonard Thompson or Kelly Martin from their open-air home, with littered dirt for a floor, castoffs for furniture and rats for roommates.
Countless times he’d shown up prepared to take Martin, a strung-out stick figure, to detox, or Thompson, crutches and all, to apply for disability benefits. Always, they’d begged off, promising to go another day.
So even Saldate was taken aback recently when Thompson sat up groggily on his mattress, paused, then mumbled, “Let’s go.”
In two hours he was signed up for disability payments of $650 a month--income he might have claimed any time in the six years he’d been homeless, begging for dollars from motorists on offramps.
“You should’ve come in sooner,” the social worker said. Thompson smiled, keeping his reasons to himself. Saldate lifted his glasses to rub his eyes, momentarily overcome.
For a man with one of the toughest jobs in health care, this was one sweet moment. Saldate is a street outreach worker who struggles to reel in the health system’s exiles--people who don’t have doctors, don’t keep appointments and often aren’t treated for life-threatening or infectious diseases until they roll in on a paramedic’s gurney.
The idea behind street outreach is simple: Don’t wait for the region’s 6thousands of needy patients to come to the hospital. Go to them--in alleys, sidewalk encampments and concrete caves beneath freeways--to find out what they need.
The approach is being tried in cities throughout the country, partly as a public health measure, partly as a humanitarian gesture. Reaching out to disenfranchised populations--the homeless, substance abusers, prostitutes and mentally ill people--"is probably the only way they are ever going to get care,” says Dr. Will Ward of Louisville, Ky., who organized a medical outreach project that has become a national model.
Why help those who can’t, or won’t, help themselves?
The answers range from the spiritual to the practical. One argument is that all human beings have a right to health care. But, to critics with bottom-line concerns, supporters also stress the democratic nature of contagious disease: It can strike anyone. And delaying care until it is most expensive strikes all taxpayers--smack in the pocketbook.
In many cities, including Los Angeles, nonprofit outreach efforts are having an impact, but success is limited by the overwhelming need. “The number of people falling through the cracks is growing,” says Dr. Chris Abbott, medical director of St. Vincent De Paul Village in San Diego.
Seeking out patients has taken on urgency in this era of managed care. Even well-heeled consumers have difficulty navigating the modern medical maze; disadvantaged clients often don’t know how, and aren’t welcomed when they try.
Another impetus for the outreach movement is welfare cutbacks, which have pushed some people to the social margins--out of low-rent hotels into the streets.
Street outreach strains the narrow definition of health care--stretching it beyond treating tuberculosis or foot fungus to addressing social and psychological ills. In hard-to-reach patients, these problems are so bound up with their physical status that it is impossible to separate the strands.
For their part, outreach workers must do a strange dance, supporting people without coddling them, offering help without forcing it upon them.
“I don’t do attack therapy,” says Darlene Moseley, who works for a Culver City outreach agency called Prototypes. She catches her clientele--mostly prostitutes at risk for AIDS, and for passing it along--between tricks on the sidewalks of South-Central Los Angeles. She hands them condoms and talks fast.
“It’s not my place to push. I can’t save them. . . . [But] I tell them, ‘I’ll always be there.’ They say, ‘Dang, my own mama won’t even do that.’ ”
From ‘Poison’ to Antidote
Saldate knows these downtown streets. He grew up in Elysian Valley as a member of the Frogtown gang. By age 12 he was hanging out in front of a Main Street boxing club; he did drug deals on these corners.
Driving past the “Berlin Wall” covered with street people’s poetry, he arrives at Sixth and Crocker, where he once saw a woman give birth while hitting on a crack pipe.
The street people remind Saldate of the person he used to be--the homeboy whom mothers dreaded having their sons bring home. Hooked on PCP and heroin, he used to awaken badly beaten from fights he didn’t remember. Once, he overdosed and nearly died in a stolen car.
“I was poison, man,” he says, unfolding his right arm to show an enormous peacock tattoo--an elaborate disguise for track marks.
Saldate changed--after many tries and many failures. He took 13 stabs at detox on methadone. Finally, nine years ago, he got sober in a Christian men’s home. He’s been working with homeless people ever since. Now 38, he’s supporting a wife and four children, earning a college degree and moonlighting as a pastor.
Saldate’s nonprofit employer, Homeless Health Care Los Angeles, offers some medical services and referrals, but much of what it provides is not conventional medicine: food vouchers, emergency shelter, help finding permanent housing, substance abuse counseling, job training. Saldate runs a weekly men’s group in which addicts talk about trust--mostly about why they trust no one.
What has all this got to do with health?
Studies show that social conditions, especially poverty, are inextricably bound to ill health. Poor people get sicker and die younger. With that in mind, Homeless Health Care targets “the people in our society that no one else wants to deal with . . . drug-addicted, alcoholic, HIV-positive, homeless mental patients,” says David Langness, chairman of the agency’s board.
Every Wednesday, Saldate makes house calls.
One day, clad in shorts and a muscle shirt, he turns into a downtown alley to talk to a red-eyed young woman in a worn sun hat. He’s midway through his spiel about free drug treatment when she runs off to catch a trucker, engine running, awaiting quick sex. She hurriedly promises to call Saldate; he guesses that she’ll lose his card.
He heads for a sidewalk dwelling nearby, fashioned from pallets and rags. “I’m not in the mood, OK?” a woman bellows from within, before Saldate can say more than good morning.
Saldate doesn’t push it. “That’s their right. I’m there at their house.”
These are cold calls--always tough--but his greatest challenge is some of his regular customers. Thompson and Martin have become a project.
When he pulls up to their urban cave, an encampment between bridge pillars, his reception depends largely on whether one or both of them is “sick"--hurting for drugs. He’s greeted more warmly when they have “gotten well.”
The dynamics between the couple are tricky, a mixture of devotion and discord. When Martin gets out of jail or detox, she always makes her way back to Thompson. He panhandles for both of them. They sleep cuddled together on an abandoned mattress.
But sometimes they don’t speak. Martin complains Thompson is inconsiderate and messy; Thompson is jealous of Martin spending time with other men. Saldate avoids taking sides, figuring he can’t help one without the other.
Their troubles run deep. Thompson, 45, admits he’s been a “dope fiend” since he was 19. He’s been shot by family members and drug dealers; one bullet is still in his body. His wife threw him out in 1992. He hasn’t had much contact with his two grown children since.
Martin, 36, has flirted with sobriety--going as long as 90 days--but it never sticks. Her lifeline to stability broke more than a year ago when her only close relative, an uncle, died in a car wreck.
“What will it take to get you to the Social Security office?” Saldate asks Thompson one day, gesturing at the refuse. “Do you like it here?” Behind a wall, a line of rats lies dead, poisoned by Thompson.
It’s an old conversation. Thompson says he’d love to be in a hotel but he’s not leaving Martin on the street. He explains that she’s hooked on drugs. He’s still using, he says, but he’s not hooked.
Meanwhile, Martin suddenly stops ranting about Thompson’s sloppiness and rubs both hands over her worn face. “I’m tired,” she sighs.
Saldate makes a date to take her to detox the next morning. When he arrives, Thompson is asleep and Martin is nowhere to be found.
‘We Have to Go to Them’
It’s hot in this office, a cramped room in a converted South-Central motel.
Darlene Moseley would turn on the air conditioning, but she doesn’t want to run up the utility bill. Her agency gets the room rent-free from Wo-man Ministries, a Christian program that houses recovering addicts and former prostitutes. She uses a fan.
As an outreach worker for the nonprofit Prototypes/Women and AIDS Risk Network, Moseley, 35, counsels and arranges social and health services for women who either live in the motel or work the streets nearby. Her immediate goal is to protect them from sexually transmitted diseases and violence. Her ultimate goal is to help them find another way to live.
Sometimes all she can do is hand them condoms and a business card.
Gathering up her keys to go out one day, she explains: “They won’t leave their work sites. We have to go to them.”
Heading down South Figueroa Street, she spots a slim young woman, her limbs jerking wildly and her head bobbing as she walks along the sidewalk.
“Is that Alvena?” Moseley exclaims. “She’s tweaking [on crack]--yeah, she’s tweaking.”
Moseley gives a short rundown: Though just 23, Alvena has four children. They live with a relative. On the street for “a long time,” she’s addicted to crack and, according to Moseley, to selling her body to pay for it.
Alvena--who did not give her last name--walks up to the car. She is beautiful, with chiseled cheekbones and wide eyes.
Raised in a family “of addicts and alcoholics,” Alvena admits she’s been using drugs since she was 17. Prototypes workers tried to help her stop. Someday she will, she says, at least “I hope so.”
“I know so,” says Moseley, herself a former addict with five years’ sobriety.
Alvena, referring to her attempts at getting clean, says, “I’m one of the ones that didn’t make it, but I have friends that have made it. It takes time for everybody.”
Alvena counts on Prototypes--not just for the day she kicks crack, but for the hard times in between. Moseley’s agency--like Saldate’s--offers drug treatment but doesn’t insist addicts be sober to get help with housing or medical care.
“When I do need something, they’re there,” Alvena says. “I don’t have the money for [condoms]. They’ve helped me find housing, food and clothes. . . . Regardless of whether I’m messing up . . . sometimes you just need someone to love you.”
Dropping Alvena off at a low-budget motel, Moseley reminds her gently, “You got my card. You got my number.”
Afterward, she vents a little. “I’ve taken her to at least six different places [for treatment]. I just have to be there for her. . . . She’s very intelligent. But she’s been through a lot, beaten, stabbed, burned with cigarettes. She’s been punched in the face so much it doesn’t hurt her anymore. She fights back.”
Moseley is trying to teach Alvena not to get into violent situations in the first place.
She pulls up near the back lot of an auto shop. An employee tells her that the teenage girl who camps there in a trailer--a refugee from an abusive Midwestern family--has been missing for days. Moseley worries that she’s been beaten or killed by a raging “john"--a hazard of the trade.
The johns are cruising up and down Figueroa and side streets. Moseley points out one creeping along in a Lincoln Towncar, a crucifix dangling from his rearview mirror. Many will pay a premium for condom-less sex, she says; some get violent when women refuse.
Moseley offers women her own modest incentives--free toiletry bags, including nail polish and a special necklace--just to listen. Sometimes her car draws a crowd.
Several days a week, Moseley’s more successful clients gather in her office for one-on-one counseling. Most have been abused--emotionally, physically or sexually--all their lives.
“I’m learning how to live life on life’s terms,” says Arlise Larkette, 33, a mother of six, who has been off drugs for six months. She recently moved to her mother’s house in Carson.
“I grew up being raped,” she says, adding that she became a prostitute at age 12, then fell into a 14-year drug addiction. On Jan. 21 this year, she was raped again.
Mosley has been helping her to deal with that. She also arranged some doctor visits, where Larkette was shocked to learn that she needed treatment for “a lot of diseases”: syphilis, cervical cancer, asthma and kidney disease.
Larkette remembers rebuffing Prototypes counselors who approached her on the street. But one day after her rape she walked into Moseley’s office to talk. Slowly, through many conversations, they built a bond. “I love you, Darlene,” Larkette says before leaving to catch a ride home.
Practical, and Moral, Reasons
Is this work worth all the trouble?
Besides being good public health policy, it makes economic sense, advocates say. “One of the ways to cut costs is to make sure people don’t come to you [when] they are dying,” says Vivian Brown, co-founder of Prototypes. “Outreach is prevention.”
Street people are considered logical targets because they usually lack health insurance and have high rates of tuberculosis, HIV and other chronic illnesses.
Yet advocates have other motivations. “It’s the right thing to do,” Louisville physician Ward says simply. “It’s caring about your fellow man.”
Practically and morally, Langness believes that grass-roots outreach has something to teach the larger health system, which he says has largely ignored prevention and instilled an “individualistic, John Wayne notion that health care is your responsibility and no one else’s.”
Some say outreach must have limits when people are not motivated to help themselves.
“I would be careful about spending vast amounts of resources when the cost-benefit is so low,” says Douglas Besharov, a public policy expert at the American Enterprise Institute.
He suggests, as well, that society needs to intervene earlier when people make poor health-care decisions. “As a society, we have become less willing to step in when judgment fails,” he says. The result: People are “choosing to” freeze to death on sidewalk grates.
On bad days, Saldate sees the appeal of coercing people into care.
“You want to put a chain all around ‘em,” he says of his clients. “But you can’t do that. There’s an old saying: People changed against their will are of the same opinion still.”
His challenge is to encourage healthy choices in people who haven’t had much practice.
That is “intensive and expensive,” says Mark Casanova, Homeless Health Care’s executive director. His agency, with an annual budget of $1.2 million, carries an annual caseload of up to 400 enrollees--15 clients per counselor--a tiny fraction of the 90,000 homeless people in Los Angeles County, as estimated by social service agencies.
Outreach workers like Saldate stress that they see some remarkable turnarounds--the former panhandler who landed a low-cost apartment, the former client who is now a counselor. Yet they struggle daily with the Thompsons and the Martins of the world.
Thompson credits Saldate with his recent good fortune, assuring him it was Saldate’s persistence that prodded him to finally apply for benefits. Saldate says he’d rather Thompson credit himself--and spend the money wisely.
Privately, Saldate worries that Thompson might blow the whole wad on drugs. But other than helping him rent an apartment and putting in a plug for drug treatment, he fights the impulse to tell Thompson how to spend it.
“You know what?” he says. “It’s his life. I’m hoping Leonard does the right thing.”