Photos by Phuc Pham

Skid Row, 8:30 a.m.
The day begins on Crocker Street in downtown Los Angeles in a shady, fenced-in courtyard behind the Volunteers of America building.

A team of health and social service workers gather with cardboard coffee cups in hand, chatting and planning for the work ahead. They form a circle, and a group leader steps forward:

What are we offering today?

Team members call out the services available: help for mental health problems and substance abuse, and referrals for doctor visits.

They grab water bottles, clipboards and radios and step through the gate into the eerie morning stillness of Skid Row.

Beyond Band-Aids

Outreach workers spent the next three hours walking the streets and encampment-covered sidewalks of Skid Row’s 54 square blocks, offering to connect the mostly homeless men who live there to physical and mental health care.

These referrals are a short-term goal, but the larger agenda is long-term.

“We are completely oriented to getting people into housing. We’re not there to offer Band-Aids to people on the street,” says Marc Trotz, director of Los Angeles County’s Housing for Health office. “I mean, we’ll give someone a Band-Aid if they need it.”

In late November, Trotz’s office announced plans to expand the outreach initiative from about a dozen care providers walking Skid Row once a week to at least 24 people five days a week. They will divide the neighborhood into quadrants, connect the chronically homeless to health care and get them into permanent housing as quickly as possible.

“We’re trying to bring a different sensibility, not business as usual, more like a natural disaster,” Trotz says. “This is an emergency; there are people dying on the street.”

That point is demonstrated daily to Trotz and his staff, who within the last year moved their office to a Skid Row location. His office also established a medical clinic in the Star Apartments, an affordable housing project in Skid Row for formerly homeless people.

“I need all that.”

Walking with the outreach workers, as I did for several hours recently, dispels any doubt that life on Skid Row is a health crisis. My guides were nurse Julia Cross, who works at the nonprofit Illumination Foundation and Christopher Mack, who represents the JWCH Institute, which operates clinics for underserved patients.

Some health issues are obvious to a first-time visitor on Skid Row: a man with a tumor-like abnormality covering one side of his face, for example, or drug users lying on the sidewalk in a seeming stupor. Other problems are revealed in conversation.

Standing outside a soup kitchen on a recent morning, a woman showed Mack a swollen spider bite on her leg. He gave her a referral to see a physician at his clinic and then asked if she needed assistance for dental, mental or other physical ailments.

“I need all that,” she said.

A young heroin user lay sprawled on the sidewalk. He was recovering from being hit by a car. Cross stood over his body, which was under a plastic tarp, and asked about the abscess on his shoulder.

“I popped it,” he said from under the tarp. “Can I see it?” she asked, sliding the tarp from his face and shirtless torso. Then she radioed in for a team member to bring antibiotics. She reminded him to take a pill once in the daytime and once at night.

A few days later, a very pregnant woman sat cross-legged on the sidewalk, seemingly oblivious to her surroundings even as her boyfriend stopped by to verbally abuse her. When she finally got up and began walking away, Cross and police followed her discreetly, observing.

They hoped to “5150” her, which is police terminology for temporarily confining someone to a psychiatric facility involuntarily. Cross was concerned she might give birth on the street and dispose of the newborn. There are disturbing precedents for childbirth on Skid Row.

“All I have left”

Cross and Mack have a relaxed manner with Skid Row residents, and their attitude engenders trust. Still, numerous homeless people politely but resolutely refuse help, or they never use their referrals to clinics or hospitals.

Time will tell if outreach workers can overcome such deeply rooted resistance.

“The narrative is, ‘Don’t tell me what to do’,” Mack explains. Some people on Skid Row have lost so much already that they decide, “Freedom is all I have left.”

Another reason for turning down help is that many housing programs require homeless people to conquer their addictions before moving in and then to submit to regular drug tests.

But the “housing first” movement is changing the order in which homeless people receive assistance. In many places, including the Housing for Health Office, the goal is now to house people quickly while also getting them into mental health, substance abuse and medical services – all under the oversight of intensive case management.

The argument is that it’s nearly impossible to get better while living on the street and fending off the elements, hunger and possible violence, much less keeping wounds clean, getting to AA meetings and refrigerating meds.

“You could lose them forever.”

Los Angeles County officials have budgeted $4 million for rental subsidies to sustain people permanently in their own homes, with1,000 placements in the last year and 1,500 in the pipeline countywide.

Typically, placement experts can move more quickly using local funds than they can with federal housing vouchers, which have more restrictions. Placement staff have been able to find landlords willing to work with residents who can pay at least part of their rent from disability and other types of assistance.

Another funding source is a recently clarified Medi-Cal provision under the Affordable Care Act that can pay for case management and other housing-related services, though not directly for rent. The city also is playing a role: Council member Jose Huizar pledged funding for the operating coordinator’s position under the expanded outreach in Skid Row.

Eventually, Trotz hopes that future funding will come from savings in reduced emergency room visits and repeat hospitalizations commonly associated with chronic homelessness, which have been widely documented.

“It’s terrible for the health care system and taxpayers to pay $80,000-$150,000 a year on someone’s emergency medical interventions,” Trotz says. “We’re saying let’s spend $20,000 a year and put them in supportive housing.”

But for now, more housing is sorely needed, causing some health workers on Skid Row to wonder whether permanent apartments and adequate resources will be available in time for the expanded outreach efforts. If not, the result could be irreversible.

“If somebody needs something and you can’t help them, you could lose them forever,” Cross says. “It’s an opportunistic sport.”