OS ANGELES — She wears no doctor’s coat, just jeans and a bright T-shirt. Dr. Susan Partovi’s medical bag is a backpack. Her office is Skid Row.
It is the nation’s most densely concentrated population of homeless people, a shadowy echo of a pulsing downtown, with thousands surviving in tents and doorways on the streets just south of glass skyscrapers. The smell of urine is pervasive. There are very sick people everywhere.
Partovi is a familiar face here. People fist-bump her as she walks past, update her on results of their latest tuberculosis tests, and ask her to look at all manner of skin rashes, fungal infections, and insect bites. She calls everyone, including a woman sprawled out on the sidewalk with no pants, “honey,” or “sweetie.”
Today, she and her team are looking for specific people who need help. One is a pregnant woman they are hoping will move into interim housing. Another is an overweight woman with swollen ankles and sky-high blood pressure who has been living on the same city block since October, with one tent, two suitcases, and an extremely sooty dress. Her skin is so sunburned, it’s impossible to tell her race or her age.
Partovi wants to get her medical care and an apartment, but she keeps refusing. She no longer lets Partovi take her blood pressure. “I’m fine, I’m fine,” she says. “In a year, maybe I’ll try an apartment.”
Partovi accepts that, for now. She accepts the pace of this job: Move slowly. Speak respectfully. Listen. And wait. With some of the most downtrodden, it’s months, or even years, before she makes any headway.
“The point of street medicine is developing a relationship,” Partovi says.
“I actually have seven cats in my house right now because there’s a homeless woman who needed cancer treatment but she was worried about her cats,” she says. “A doctor should not be taking care of cats. But there you are.”
“Wounds are festering, diabetes is out of control, cancer is metastasizing. You really are in a disaster zone.”
Dr. James O’Connell, Health Care for the Homeless
Partovi, who is 48, has been doing this work for a dozen years, scraping together a living by working for various clinics, nonprofits, and Los Angeles County.
Despite a multitude of efforts, the problems so visible on Skid Row are spiking: The chronic homeless population in the county has jumped 55 percent in recent years. There are nearly 47,000 homeless individuals in the county, and nearly three-fourths of them have no shelter at all, other than tents, cars, or cardboard boxes. All the while, just blocks away, downtown LA is booming, drawing trendy restaurants, a Whole Foods, and a steady stream of residents who are scooping up million-dollar luxury apartments.
Under pressure to address the homeless crisis, the county recently launched a new outreach effort. Every weekday now, four teams of six, including mental health and substance abuse experts, work their way through the streets and alleys of Skid Row — a swath of staggering need that covers roughly 50 square blocks.
Partovi, who has spearheaded the county’s smaller outreach efforts for years, joins the teams once a week. She’s also the medical director of Homeless Health Care LA and works at Skid Row clinics, one connected to a needle exchange.
Her patients are weary, damaged, and sometimes extremely dirty. They come in with gruesome infections and abscesses hugely swollen with pus. She treats them with dignity, often examining them without gloves. Partovi has been repeatedly treated for the highly dangerous, antibiotic-resistant infection MRSA, which runs rampant on Skid Row. An acquaintance who also ministers to the homeless, Rev. Andy Bales, recently contracted a flesh-eating strep and staph infection that cost him a bone in his foot.
None of it fazes her.
“Susan really is a force. She has really been willing to take risks to take care of people,” says Dr. James O’Connell, a pioneering street doctor who is also an assistant professor of medicine at Harvard Medical School.
“She’s badass, is what she is,” says Dr. Jim Withers, who has ministered to the homeless in Pittsburgh for 23 years.
‘It’s kind of germy in my alley’
Street doctors tend to the country’s neediest and sickest. Homeless populations are racked with high rates of heart disease, cancer, liver disease, kidney disease, skin infections, HIV/AIDS, pneumonia, and tuberculosis. There are high rates of mental illness and addiction.
“Wounds are festering, diabetes is out of control, cancer is metastasizing. You really are in a disaster zone,” says O’Connell, who is president of the Boston Health Care for the Homeless program. “You see things you had only seen in textbooks.”
On a recent day, Partovi sees a 65-year-old Hispanic man who lives in a nearby alley, getting by on sweeping, recycling, and keeping watch over a few businesses. He wears two pairs of jeans and has a long, salt-and-pepper ponytail.
He’s a heroin user, and his arms are scarred from needle marks and old abscesses — wounds that form when people miss veins, shoot through their clothes, or use dirty needles. The abscess on his left arm is the size of a navel orange and so painful he can no longer ignore it, so he’s come to a clinic run by Homeless Health Care Los Angeles, a nonprofit.
“I couldn’t tolerate the throbbing,” he tells Partovi.
Partovi injects the abscess with lidocaine to numb it and then unwraps a large, 60 cc syringe to drain it. It’s so large, she has to pull really hard on the syringe to pull out fluid. She then pushes down hard on the abscess. Despite the lidocaine, her patient is groaning in pain. She injects more painkiller and keeps pushing as blood and pus sluice into a plastic foam cup.
“Oh yeah, we got half a cup out,” she says.
“You done yet?” he asks, clenching his teeth.
She’s not. She asks a resident who is shadowing her to probe a swab into the wound to see if it’s tunneling into the surrounding tissue. “Don’t be gentle,” she says. Partovi keeps squeezing. More fluid comes out. She’s a pro at this: Her colleagues call her the Queen of the Abscess. She even demonstrates the technique in a YouTube video, not for the squeamish.
Once it’s done, Partovi twists gauze into strips — they’re known as “Partovi twisties” in the street medicine community — and asks the resident to push them into the wound. All the while, she’s giving instructions on how to change the dressings. Her patient seems hesitant.
“It’s kind of germy in my alley,” he says.
She tells him it’s important to keep the wound clean and moist, but says she’ll change the dressings if he wants to come back. She then places dozens of pieces of gauze on top of the wound to catch the drainage, tapes up his arm, and hands him some antibiotics. He’s hugely relieved.
“I go out of my way to see that they’re coddled.”
Dr. Susan Partovi
The average life expectancy for those on the streets is under 50, compared to 78 for the general population. “These are the most excluded, the most disenfranchised,” says O’Connell. “The cardinal rule is, you cannot wait for someone to come to you. If you wait, they’ll never come.”
So the doctors go to them. Under bridges. Down alleys. On summer days so hot the pavement in Los Angeles seems to sizzle. During 5-degree winter nights in Pittsburgh.
“If I’m with someone under a bridge in a snowstorm, they get the message that they matter,” Withers says.
Street docs try hard not to look like doctors at all: Withers often rubs dirt into his hair and clothes before hitting the streets. O’Connell carries very little. Partovi wears normal street clothes with a little flair: She’s rarely without her dangling turquoise earrings and cowboy boots.
The work takes medical knowledge, compassion, and loads of patience. Partovi is not aggressive. She makes eye contact, asks how people are doing, and waits to see how they respond. She’s learned how to quickly assess someone’s health visually even when they won’t tolerate standard medical tools, like blood pressure cuffs. “Popeye arms” might signal repeated drug use. Unhealed sores: diabetes.
If all patients will accept is a Band-Aid, or a bottled water, or a chocolate protein bar, she doesn’t press, even if they clearly have far more urgent needs. “After a couple of times, they might let you take their blood pressure,” she says. “They might follow you back to the clinic.”
A life focused on ‘poverty medicine’
Partovi grew up a child of relative privilege in wealthy West Los Angeles and Malibu, the daughter of a Jewish-Iranian aerospace engineer and a schoolteacher. Despite the financial comfort, she says she didn’t have a great or loving childhood. Her emptiness led her away from her family. She converted to Christianity and began attending a local church.
For five years, she joined the church’s monthly trips to Tijuana to aid families squatting at garbage dumps.
That did it: She was hooked on helping the poor.
“I get the sense she needed to be cared for, and then she started caring for other people,” says Dr. Elaine Goldhammer, an internist in Philadelphia who has known Partovi since they attended Thomas Jefferson University’s medical school together two decades ago.
Partovi worked for a time at the county’s Harbor-UCLA Medical Center, then shifted into caring for the homeless. She calls her specialty “poverty medicine.”
In her spare time, Partovi hikes, bikes, and hangs out with her four dogs, whom she calls “my children.” She also travels regularly to care for impoverished children in rural Haiti. She and Goldhammer have started a nonprofit called H.E.A.L. to take medical students to Haiti — not only so they can help the locals, but so the future doctors learn to see such work as viable career choice.
Partovi does get troubled by some of what she sees: Children dying of malnutrition in Haiti, adults with severe mental illness on the streets of Los Angeles without shoes. But she’s not at all burdened by her work, or burned out. She loves her patients.
“It’s not a sacrifice,” she says. “It’s my choice.”
In fact, her physician friends suspect that she may be happier than many of them.
“The rest of us are in the corporate cycle of being drowned in computer work and being told we aren’t seeing enough patients,” Goldhammer says. “It’s the rest of the world that’s burning out.”
Coddling the homeless
Partovi’s clinic is anything but grim. She plays pop music constantly from a small boombox. She usually has a smile, a laugh, a soft — and often ungloved — touch for her patients.
“She just sort of accepts everyone as they are, which is the draw to her,” Goldhammer says.
“Some of our patients won’t go elsewhere,” says Dr. Sean Enloe, a retired forensic pathologist who now volunteers in the clinic.
Many homeless people are ashamed to go to Veterans Affairs hospitals, even when they qualify for care, because they’re using drugs, he says. They’re afraid of local emergency rooms, where they might be treated badly. A number of local hospitals have been fined for dumping homeless patients on Skid Row late at night, often without their clothes, wheelchairs, or walkers.
Enloe and Partovi fume as they recall the story of one homeless man who was not given anesthetic in a local ER while having an extremely painful abscess drained.
“They told him: ‘I hope you feel this,’” Partovi says.
She takes a different approach: “We know they use. We’re not here to lecture them,” Partovi says. “I go out of my way to see that they’re coddled.”
“She just sort of accepts everyone as they are, which is the draw to her.”
Dr. Elaine Goldhammer on Partovi
A 20-something woman with short, brightly dyed hair and a fresh sunburn comes into the clinic for a pregnancy test. It’s negative, but Partovi uses the visit to find out the young woman’s story. It’s a common one: She had come to Los Angeles from out of state with the promise of a job and a place to live. Neither panned out. A heroin user, she ended up on the streets just three weeks after arriving.
“Things crumbled pretty much right after I got here,” she tells Partovi. “I don’t even have a tent.”
Partovi slowly starts to take her medical history.
Through a series of straightforward questions, Partovi finds out the young woman is using heroin twice a day — “just enough not to get sick,” the patient says. She’s overdosed once and been through detox, but it didn’t stick. She’s tested negative for hepatitis C and HIV. She’s long struggled with mental illness. Partovi ticks off a long list of drugs — Xanax? Depakote? Lithium? Zyprexa? Lexapro? Buspar? — to find out what the young woman has taken and what might help her now.
“Do you hear voices?” she asks gently. “Do you get manic?”
“Sometimes I feel like everybody hates me,” the patient says, tattooed fingers nervously clicking her pen.
As they talk, Partovi offers tips: where to apply for Medi-Cal benefits, where to get free birth control, where to get seen by a psychiatrist and how to catch a free shuttle to get there.
When the young woman mentions she really needs a place to keep her belongings, Partovi tells her how to get a free garbage barrel at “The Bin,” a nonprofit that stores and safeguards close to 1,500 bins for Skid Row’s homeless.
“When you’re ready, we offer detox — Suboxone,” says Partovi. “If we have the money, we can get you a hotel room for the first few days.”
She spends a full hour with the patient. That’s unheard of in most primary care settings. Indeed, street doctors argue that they provide far better, more humane care than most well-insured Americans get from 15-minute annual checkups with their doctors. Though it may be under bridges or in alleys, they even make house calls.
“She’s the new face of health care,” Withers says of Partovi. “We in street medicine are part of a larger awareness being raised that traditional health care isn’t working. What we do now is just billing and processing people; we’re not looking at what’s going on in their lives.”
After the young woman leaves, Partovi takes a deep breath. “It breaks my heart,” she says. “She’s so young.”
An ocean of staggering need
With more than 2,000 people sleeping on the streets every night, Skid Row is a hellish city within a city. Each night, hundreds of tents line the streets for blocks, many with wheelchairs parked outside.
In the mornings, as city workers power wash sidewalks, single shoes, down coats, and 40-ounce malt liquor bottles tumble into gutters. One man hawks cigarettes and lighters; another sells travel-sized toothpaste tubes. For a few dollars, a woman will do up hair into braids, weaves, or cornrows. A man trying to sell marijuana gets shouted away: A synthetic form of the drug, called “Spice,” recently caused 14 overdoses here on Skid Row. The street knew about the problem days before the news hit local papers.
Partovi and her team walk through the crowds, looking for that pregnant woman they’re hoping to coax into housing.
Everywhere they look, they see need.
“Tardive dyskinesia,” Partovi says as a middle-aged woman walks by, grimacing and pursing her lips as she pushes a fully loaded shopping cart. She’s wearing a hospital gown. Her disorder affects the nervous system and causes involuntary tics. It’s often caused by years of taking psychiatric drugs.
A man across the street has a catheter — and an extremely full urine collection bag dangling from his wheelchair.
Partovi and her team don’t stop. In a sea of pain, these cases don’t stand out.
They do pause briefly to help an elderly Hispanic woman who is slumped under a No Loitering sign, dressed in five sweaters despite the hot morning sun. Her sneakers are strapped together with red duct tape. Partovi and others try — in English and then Spanish — to persuade the woman to move to the shade on the opposite side of the street, but have no success.
“Susan really is a force. She has really been willing to take risks to take care of people.”
James O’Connell, Harvard Medical School
The team then checks the Midnight Mission, a privately funded program that serves three meals a day to 500 clients at a time. Outside, in the landscaped courtyard, dozens of people wait for their next meal. Some are sleeping, some are smoking. A few put on makeup. Many read: the Bible, “Twilight,” a textbook called “The Encyclopedia of Terrorism.”
A middle-aged African-American woman, wearing a pink smiley-face T-shirt, glittery bracelets, and slippers, approaches.
“I had this abscess opened a week ago,” she says, exposing a bulging patch of gauze and tape on her upper arm.
“Have you changed the dressing?” Partovi asks. She hasn’t.
Partovi has the woman find a spot to sit, then roots through her backpack for supplies. She pulls off the old gauze and exposes an open wound some 2 inches long and oozing slightly. She probes the wound a bit — it’s healing well. She packs it with gauze, tapes it, and pulls a bottle of antibiotics from her backpack.
“You’re the best of the best!” the patient shouts.
Partovi moves on. She’s been on the street less than an hour. There’s still no sign of the pregnant woman, but as Partovi crosses the street, another woman — elderly and black, a double amputee in a battered wheelchair — waves her over, pointing at an infected ear she’s been scratching with a bobby pin.
“Hi, sweetie,” Partovi says. She bends over to examine the ear.