Treated With Respect : Skid Row: Women find haven from street life at a clinic whose founder believes in showing patients ‘we care about them as human beings, not just as body parts.’

It is Wednesday on Skid Row and Estrella Garcia, about to be homeless because she can’t pay the rent for her tiny shared room, is back for a third visit to Safe Harbor Women’s Clinic.

Each visit has been for what Garcia describes as “female problems,” says clinic founder Pam Shuler, a nurse practitioner. Each proves dramatically more complex.

“She came here for gynecological problems, which we took care of,” Shuler says, “but we noticed she was very, very, very depressed. And with good reason.”

Today, however, Garcia’s jeans and blouse are freshly washed, her long hair squeaky clean. Six weeks ago, Garcia had no will to live, let alone to wash her hair.

“Right now, the only thing that keeps me going is this clinic,” Garcia tells Shuler. “If it weren’t for you, I’d have no one at all.”

Until two years ago, there weren’t many health-care options for women like Garcia. That’s when Shuler appeared on Skid Row, taking over two tiny rooms in a Salvation Army building on 5th Street and declaring her women’s clinic open for business.

When patients didn’t come, Shuler went looking for them. “Good morning, I’m Pam, what’s your name?” she gently asked women camping on the street.

Then she’d chat a while and explain how the clinic worked, repeatedly using the woman’s name. It seems like a small thing, she says, but homeless people sometimes aren’t called by name for months or even years; some forget who they really are.

Shuler is full of such specialized lore, an expert on things important to the poor but inconsequential to most others.

“Years ago I realized there was no guide for health-care providers who work specifically ith the poor,” she says.

So Shuler wrote one.

It’s a framework and philosophy--a step-by-step plan for nurse practitioners--that details how to interact with poor people to find their problems and deliver meaningful care.

“It’s holistic in nature, because you can’t take the physical ailment out of context of a person’s whole life,” Shuler says, especially with people who may not have access to basic amenities others take for granted.

Then she opened her Skid Row clinic and started practicing what she preaches in her innovative plan, which will be published in the Journal of the American Academy of Nurse Practitioners.

In long kaffeeklatsches with each new patient, Shuler discusses everything from religion and sex habits to when and where the woman took her last bath.

The conversations--seemingly casual and unplanned--are actually formalized in a printed assessment Shuler has devised to cover every aspect of a woman’s life. Any health-care worker can follow the format, which Shuler says “shows patients we care about them as total human beings, not just as body parts.” More important, it is designed to illuminate potentially serious problems the patient may not know she has.

Poor people worry about survival, she says, and don’t pay attention to physical symptoms that might make other people shudder.

Her shoestring operation, open three days a week, seems to be a hit with the 1,000 women it has served. Each patient is checked for problems with thyroid, heart, lungs and abdomen; each gets a complete pelvic exam, Pap smear, tests for chlamydia, gonorrhea, syphilis and vaginal infections. Each is taught about sexually transmitted diseases, given condoms and shown how they should be used.

“It’s a pioneer effort” that seems to work, says Dr. Carol Henneman, obstetrician/gynecologist at H. Claud Hudson, an L.A. County medical facility. “It seems cost-effective, too.” (Space is donated by the Salvation Army, medical supplies by the county and the salaries of the four staff members come from charitable foundations.)

Henneman and others say more clinics like Shuler’s might help stem the rising tide of infectious illness that often afflict poor people--and for which the rest of society usually pays.

“Poor women are intimidated by the complex (county) system,” Henneman says. “We’re looking to access them in any way we can.”

Access is no longer a problem for Shuler. Word of mouth about the clinic has spread along Skid Row.

Shuler, 36, grew up in rural, middle-class North Carolina. She says she realized early that some of the nicest people she knew were also some of the poorest. But the poor weren’t respected, Shuler saw, and rarely got chances to break out of poverty.

What bothered her most, she recalls, was that they couldn’t afford to see a doctor when they got sick.

Shuler decided to change things.

She took a master’s degree in nursing at the University of Arkansas and a Ph.D. in public health nursing at UCLA. She became a nurse practitioner--licensed to diagnose and treat certain illnesses and to spot those that require a physician’s care.

All along the way, Shuler says, she’s been working with the poor--and assembling the pieces of a treatment plan for women like Estrella Garcia.

About four years ago, Garcia, 38, came to the United States from Mexico with her husband, Shuler says. Garcia became pregnant and an U.S. obstetrician gave her an ultrasound test and told her to expect twins; she even heard two heartbeats on the doctor’s equipment, Shuler says. Garcia went home to Mexico in December, 1988, to be near her family for the births.

After delivery by Cesarean section, during which she was anesthetized, Garcia says she was given only one baby. The Mexican doctor said she had never carried twins, that the American doctor had been wrong. Garcia believes one baby was stolen, but police would not investigate.

Anguished, Garcia left her baby with her mother in Mexico and returned to her husband in the United States.

He died in a car accident last month and Garcia was left with no money and no friends.

Shuler recalls Garcia’s first trip to the clinic: “She was filled with unresolved grief. She was so grateful that we listened and sympathized; no one else had.”

During today’s visit, Shuler asks Garcia if things are going better for her. Garcia replies that she can’t get work because she doesn’t have a letter of reference; she can’t get one because she hasn’t worked.

Shuler writes a letter saying Garcia has no diseases and is responsible in keeping clinic appointments. “It’s not a job reference, but it will let them know you are respected here,” Shuler says.

Respect--as much as medicine--is what has begun to pull Garcia out of her despair, Shuler says as she continues a seemingly social chat with her about what’s going on in Garcia’s life.

About an hour into the visit, Shuler gets to the physical exam. An abdominal swelling she had found before has not yet been diagnosed by doctors at County/USC, where Shuler had made an appointment for her. Shuler says she’ll call the doctors to find out what’s causing the delay.

Barring a serious health problem, Shuler says Garcia probably will find meaningful work and use her considerable intelligence to build a happy life.

Garcia laughs shyly.

The days whiz by for Shuler, each a series of emotion-charged sessions:

One day, a clean, articulate, recovering alcoholic comes back because she “feels weird.” Shuler discovers her blood pressure is 220/140 and suggests she go immediately to a nearby Urgent Care facility.

A disoriented young woman, dressed in what appears to be a bolt of cloth fastened with safety pins, comes in but wants to leave abruptly, saying “I feel too dirty to be here.”

“Showers are down the hall,” Shuler smiles. “And take your time--we’ll talk whenever you get back.”

Andrea, 26, a pretty, well-groomed, “temporarily homeless” woman, says she’s bothered by stomachaches. The real problem, it turns out, is her recurring, blinding headaches. Andrea does not think the headaches are significant; Shuler explains that they could be and phones to make an appointment with an eye doctor at a nearby clinic. She gives Andrea medication to soothe her aching stomach and suggests a new diet: “Promise, no more pork rinds for a while.”

Emily, 42, has been referred by a Catholic agency. Conversation reveals that she prays a lot for her two daughters, ages 4 and 11; that the girls eat only lunch--no breakfast or dinner; that Emily’s husband won’t let her work, which leads to a chat about macho husbands in general and her husband in particular.

Soon, tears begin. Emily confides that her husband abuses her and the children, that she has tried to leave but that he says he’ll find and kill them. The dialogue continues until Emily understands that she is not alone, that there are safe houses where she can hide--and that the clinic staff will help her. Suddenly, beaming with hope, Emily lies back on the table for her physical exam.

A swelling “the size of a five-month pregnancy,” is discovered in her abdomen, but the nurse tells her it is “probably not serious.” Emily will go to County-USC to have it evaluated.

During more small talk, Emily says she became blind in one eye about a month ago while hanging a curtain in the family’s Skid Row room. She hasn’t seen a doctor about it and doesn’t intend to. She is gently persuaded to do so.

Another day at the clinic has ended. Shuler goes home to West Los Angeles and her musician husband. She will worry about her patients, she says, and about others who may never get help unless more clinics open in poor areas.

It’s something unlikely to happen any time soon. In fact, few in the medical Establishment know about the clinic or Shuler’s idea of tapping into the lives of poor women to find health problems before they become too serious--and too expensive--to treat. No delegations of doctors have come to observe the clinic.

Although county health-care providers accept referrals from Shuler, giving her patients an edge over those who walk in off the streets, observers note that the county medical system is too overburdened and under-funded to implement Shuler’s ideas.

Savi Bisnaph-Malone, program director for the Los Angeles Women’s Foundation, which gives financial grants to the clinic, says “Safe Harbor fills a great need that not many are willing to address.”

And Wendy Garen, senior program director of the Ralph M. Parsons Foundation, which distributes funds to health-care organizations, praises Shuler’s creativity. Her organization has given funds to the project, she says, because Shuler “brought together a number of resources in a highly cost-effective way, networking all the (health-care) pieces together in a collaborative effort to serve these women.

“She’s smart and knows how to reach them. She has respect for them, which is why they come back.”