On the corner of Martin Luther King Blvd., El Rey Taco declares itself “Home of the Garbage Burrito.” A few blocks down, On the Right Road Deliverance Ministries advertises Sunday worship, and by 8 a.m., the doors at Prince’s Liquor Mart #6 are open for business. The sky-blue clinic peeks out from behind a row of abandoned buildings at the end of the block. The sun logo, drawn in a childlike hand, beams optimism and goodwill to the surrounding neighborhood and self-consciously proclaims its mission of community health. In contrast, the dreary waiting room and maze of mustard hallways inside betray the daily grind of patching together health care for people who need and deserve more.
After six years on the Navajo Reservation in Arizona, my husband, Carlos, and I left our jobs with the Indian Health Service to be closer to his family in Los Angeles. Carlos has returned to academic medicine, and I have taken a position at a small community health center in south central Los Angeles. Predominantly Hispanic, the community served by my new clinic is in one of the poorest areas of the country. Nearly 98 percent of the people live below the poverty line, and 89 percent are uninsured. By the time the clinic opens, a line already stretches down the sidewalk. Consistent primary care is rare. Patients bounce from clinic to clinic as their insurance status and financial resources fluctuate.
On my first day of work, presidential candidate Dennis Kucinich visited our clinic. Our CEO had hastily organized a community forum to discuss the closure of King/Drew Hospital, the only safety-net hospital in our area. The mood was very California progressive. A mother–daughter team of Kucinich groupies, with unkempt waist-length hair and flamboyant politics, cheered often and vociferously. While none defended the substandard conditions at King/Drew, all criticized state and county officials for not providing the means to restructure.
But medical care is only a small component of building a healthy community, and the forum revealed a vibrant network of committed individuals working very hard to be part of the solution. In addition to Kucinich, the forum featured speakers from local groups working to increase affordable housing, to create green space, to provide support services for the homeless, and to provide case management for those with mental illness.
After the forum, the clinical director was to orient me to my new job. “Um, one of our doctors called in sick today, and I’m pretty sure you can handle this anyway. Can you take rooms one and two?” She wished me luck as I set off down the hall to find the rooms.
Angel was one of my first patients. His blue uniform shirt strained across his overweight belly, and the embroidered monogram was threadbare. His beard was stubbly, and his olive eyes had dark circles from working the night shift. Only 41, he had already been diabetic for more than five years. His blood sugar, even on medication, was double the norm at 300. Although I could increase his oral medications to the maximum dose, there was little chance that it would bring his blood sugar into an appropriate range.
Angel needed insulin. But when I asked him about his home glucometer readings, he said, “Oh Doctora, no tengo una machina.” He didn’t have a glucometer. Angel also didn’t have insurance. Even though a glucometer itself is fairly inexpensive, the test supplies can cost more than $60 per month. No insurance meant no glucometer. Without a glucometer, there could be no insulin.
When I explained this to Angel, he accepted the information graciously. He smiled as he left and promised to return the following month. Angel’s best chance at a healthy life was to get his blood sugar under strict control, but this would be impossible without the ability to monitor his own sugars. What I had offered him was a death sentence because he had neither insurance nor money.
At 36, Catalina had been trying unsuccessfully for 20 years to become pregnant. Simple hormone testing revealed an elevated prolactin level, the hormone that allows women to lactate when breastfeeding. Because Catalina was uninsured, it would be at least six months before she could get an MRI to determine if she had a small overgrowth in the pituitary gland that can cause this problem. She would need prompt evaluation and treatment to get pregnant. Nonetheless, she had tears in her eyes as she thanked me for explaining why her breasts had been leaking milk all these years.
As an Indian Health Service physician, I felt I could provide the care that the Navajo deserved. Those living on the reservation without private insurance were still eligible for care through the Indian Health Service. From medications to specialists, from transportation to interpretation, almost everything was covered. In contrast, my Los Angeles patients are stranded in a country they have joined at incredible personal sacrifice for a chance at a better life. Today I met a young girl named America. But what did I have to offer her?
I pass Martin Luther King Blvd.and the famous garbage burrito every morning, and I can’t help but reflect on the sense of promise and achievement with which the name was bestowed on the once grand boulevard. King’s dream is far from the reality here. This is medicine beyond the safety net.
Ellen Rothman, HMS ’98, practices at a community health center in Los Angeles.
The names used in this column are pseudonyms, and the opinions expressed are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.
