Teresa Rios’ hair was still wet from the bath. She pulled it back with a rhinestone band, reached for her cane and stepped into the musty hallway of her apartment building. She counted the steps to the front: One, two . . . 22 in all. Then the stairs, four of them. Left, onto the sidewalk: One, two, three . . .
South Los Angeles was still waking up. Rios walked past the tamale man on the corner, past the homeless man washing his face in a fountain at the park, past a little bakery, its pasteles still in the oven. She crossed the street -- 36, 37, 38 . . . -- and caught the No. 754 bus, headed north on Vermont, toward salvation.
An hour later, she and 20 others gathered in a dull carpeted room at a community center. Most were in their 50s, their bodies signposts for hard-lived lives. Many were overweight. Malnutrition had left some severely bowlegged. Most had diabetes -- the disease that stole Rios’ vision.
Suddenly, Ana Ruth Varela, their leader, burst into the room. She had just changed into sneakers and she was ready to dance. She cranked up a boombox. Stretching soon gave way to aerobics and full-throated life lessons. “Movimiento! Viva una vida mas larga!” Varela shouted. “Movement! Live a longer life!”
Rios, 52, placed her cane on a folding chair and smoothed her pleated skirt with her palms. At first she padded her feet, gently, as if they had fallen asleep. Soon she was marching and swinging her arms like a drum major.
It was one quiet victory in South L.A.'s healthcare transformation -- leapfrogging squabbling politicians to turn one of the nation’s most distressed neighborhoods into a laboratory for preventive care.
‘A tremendous need’
Amid South L.A.'s many ills, it is easy to forget that it is also a very unhealthy place.
St. John’s Well Child and Family Center, the largest clinic in the neighborhood, sees 50,000 patients each year. Roughly 30,000 are children, and though St. John’s doesn’t keep track, many are undocumented immigrants -- a community, said President and Chief Executive Jim Mangia, “that we serve proudly and loudly.”
According to St. John’s, 54% of child patients have high levels of lead in their blood; the metal, a neurotoxin that hampers brain function, is a vestige of slum housing. Forty percent of adults have diabetes. An average of 12 children a week suffer either from rat bites or cockroaches in their ears. Few have health insurance.
“There is a tremendous resilience here,” Mangia said. “But there is still a tremendous need as well.”
A central piece of President Obama’s healthcare initiative strongly emphasizes preventive care, disease management and public health -- all avenues, Obama contends, for expanding access to doctors while saving lives and money.
There is plenty of debate in Washington over whether preventive care is cost-effective. A recent report in the New England Journal of Medicine found that some programs save money while others don’t.
There is little debate that the efficiency of preventive care depends on the target: the patients. Cancer screening, for instance, is most cost-effective when the target population is at a high risk for cancer. Few communities in the nation are more at risk than South L.A.
With public and private hospitals in the L.A. area’s southern end shutting down or scaling back with regularity, nonprofit community health centers in South L.A. have shed their doc-in-a-box image. A coalition of seven now provides 40% of primary care here, Mangia said.
St. John’s, once housed in the back of a church, is now a $20-million-a-year operation funded by government and nonprofit public health grants, and it handles nearly half of the coalition’s 300,000 yearly patient visits.
And it has vaulted ahead of the national healthcare debate, nudging the focus of care away from sickness -- the traditional American model -- and toward wellness.
Teresa Rios was a typical case when she arrived at St. John’s four years ago, suffering from severe headaches. She had long ago lost her vision, “and I just thought I was depressed,” she said. She was -- but she was also in an advanced, debilitating stage of diabetes. Rios’ kidneys were failing, she was in danger of losing her feet and her blood pressure had skyrocketed.
St. John’s put her on dialysis and stabilized her blood, but it didn’t stop there.
At no cost to her, staff members enrolled her in nutrition and exercise programs, like her weekly dance class. She learned about healthful eating, about proper use of medicine -- “not how to take more, but how to take less,” she said.
St. John’s connected her with Braille instructors and helped her obtain novels that were recorded on tape, which helped draw her out of a deep sadness.
She is not out of the woods, but she has lost nearly 30 pounds -- she’s down to 136 -- and now cruises around town on her own, tapping the sidewalk with her cane and counting the paces between every landmark.
“I was in really bad shape. No more,” Rios said. “I feel great. I really do.”
Some small steps
A few months ago, a patient dropped in. She’d been healthy in the past but didn’t feel well. A quick test revealed that her blood-sugar levels were off the charts. The explanation was simple: The woman had run out of money and eaten 40 tortillas -- and nothing more -- in the three days before she came in.
“Pure sugar. Carbohydrates,” Mangia said.
St. John’s treated the woman, reminding her that if she could afford 40 tortillas, she could probably afford one pepper or onion to go with them.
In response to such cases, a woman named Antonia Esparza steps out of St. John’s every few days and drops in on nearby liquor stores -- where families, in the absence of full-fledged markets, do much of their grocery shopping.
Fresh fruits and vegetables are a rarity in the poorest pockets of South Los Angeles.
Some of the liquor stores do offer a small amount of produce -- a handful of mangoes, a stack of nopales, the pads of prickly pear cactus. Store owners argue that produce doesn’t sell, but Esparza says that’s a self-fulfilling prophecy, since the produce is always displayed in the back, past the chips and candy. So she’s persuaded half a dozen store owners to move the produce to the front.
“A little thing,” she said. “But important.”
Much of the preventive care at St. John’s is handled by medical professionals, of course. For example, two podiatrists have been hired to handle diabetics. Now, patients with foot infections don’t have to wait to see a county specialist, which can take months; they see a staff specialist from their first day. Mangia believes 700 limbs have been saved this year.
But the preventive-care programs that don’t look a thing like traditional healthcare -- Varela’s dance classes, Esparza’s lobbying of liquor stores -- fall to an unusual army of outreach workers. They’re not doctors but more like social workers. Mostly middle-aged, bilingual women, they are known as promotoras.
Working on their own or with other community nonprofits, they go home with patients who come in for treatment -- diagnosing not just disease but everything in patients’ lives that is harming their health.
Dust mites are a widespread trigger of asthma, so the promotoras provide free mattress covers and lend out vacuum cleaners. Eighty percent of St. John’s patients live in housing classified as substandard; the promotoras teach parents to surround children’s beds with boric acid to ward off rats and roaches. They also connect families with tenants’ rights groups that push landlords to cover up lead paint.
They teach illiterate parents how to read food labels. After finding that many of their obese patients were eating one huge meal each day to save money, they began focusing on the importance of healthful food proportions.
Earlier this month, a dietitian began testing menus to teach patients how to cook ethnic dishes in a more healthful way. A yoga class is now offered to pregnant women. No teachable moment is wasted; every morning, Esparza takes advantage of the packed waiting room to deliver a sermon about dental care, illustrating her techniques with an enormous green toothbrush and a gigantic set of fake teeth.
A house call
One afternoon earlier this month, Nacira Torres and Silveria Romero pulled up to an apartment in South L.A., near Manchester Avenue. The two promotoras were paying their first home visit to a new client. To avoid being robbed, they’d left their purses back at the office. Graffiti covered the walls of the complex. In a patch of weeds and dirt next to the building -- where children played -- a couple of shotgun shells, a dead rat and condom and candy wrappers littered the ground.
Socorro Diaz, 33, welcomed them inside. Guajillo chiles were cooking on the stove, and the flypaper hanging in the living room was twitching; a cockroach had become stuck there. A picture was taped to the wall, done in crayon. “Our big family,” it read. Diaz offered them chairs and sat across from them.
“We are a bunch of sick people here,” she said with a tired smile.
Not long ago, Diaz told them, she and her six children -- ranging from Amelia, 15, to Anthony, 6, who insists that people call him Michael Jackson -- were living in a van. She did not have health insurance. Three years ago, she moved into this rent-subsidized apartment.
“I took it right away,” she told them. “There was no other option.”
Today, it seems someone in the apartment is always sick -- if not most of them.
They all suffer from asthma, triggered by dust mites and roaches that crawl through a gap between the stove and the wall. Water drips in day and night, through the ceiling, through the busted smoke detector on the wall. Mold compounds the asthma. At night, the kids have coughing fits. One has polyps in her windpipe.
Diaz told them she faces a Catch-22 at every turn. She uses sprays and “bombs” to fight the roaches, but the chemicals send the children into asthmatic fits. Her cats chase off the rats but contribute to their asthma too.
“It’s hard to ask for help,” she said, her eyes on the floor.
Diaz confessed she’d been forced to play doctor in their house, making trips to Tijuana to buy cheap medicines for her kids, just to see if something might work.
“Nunca mas,” Romero scolded her. “Never again.”
For two hours, Torres and Romero assessed the family and their home -- what they ate, where they slept, where the children played outside. They passed around plastic facsimiles of bronchial tubes, one pink and healthy, one inflamed and covered in mucus.
They talked about using boric acid to keep the roaches at bay, about the importance of washing your hands, about why it is a good idea to open the windows when dusting.
They went over dozens of charts and diagrams. One, about dust mites, looked like a B-movie poster: “THEY LIVE IN YOUR MATTRESS!” Others, about nutrition, were labeled “Minerales,” “Vitaminas” and “Carbohydratos.”
Diaz promised to take their advice and to visit the clinic regularly. Torres and Romero packed up their charts and bronchial tubes in a pull cart and waved goodbye.
“With some, you can only cross your fingers,” Torres said as she walked away. “You hope for them. You must.”
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About this series
This is the latest in a series of reports about public safety, changing demographics, inventive social programs and other aspects of life in South Los Angeles.