By Celeste Fremon
The Los Angeles Free Clinic opened in 1967 during the Summer of Love, when kids from around the country poured into L.A. as a bright-colored and idealistic stream. Los Angeles has always been a mecca for runaways lured by Hollywood, but the hippie movement of the late '60s brought southern California's poor and homeless youth population to critical mass. Before long, the flower children living in parks and on the street developed an impressive list of health problems: STDs, drug overdoses, hepatitis, plus the more pedestrian fare of strep throat and other garden-variety infections.
Most had no money for medical care. So a tiny group of volunteers opened a storefront clinic on Fairfax Avenue to offer kids "free, non-judgmental care": the L.A. Free Clinic. The small facility, across the street from CBS studios, became a model for the free clinic movement that spread throughout the U.S., fueled by the belief that health care was a right, not a privilege.
Thirty-four years later, the flower children are gone and many of the nation's free clinics have folded. Others charge co-payments in order to stay open. But the L.A. Free Clinic still gives away its services at the rate of 65,000 patient visits a year on an annual budget of over $6.5 million - making it the longest continuously operating institution of its kind in the nation.
These days the clinic's main location is a large, attractive, glass-front building on Beverly Boulevard in West Los Angeles that services the poor and homeless of all ages. But a second location, opened in 1991 on Hollywood Boulevard, specifically targets high-risk youth. Young people from throughout L.A. drop into the center (L.A. County's only free clinic designed for adolescents), but the clinic's main clients are the up to 8,000 homeless and runaway kids currently estimated to be living on the streets and in the shelters of Hollywood.
"They picked about the hardest imaginable population to serve," says Mandy Johnson, executive director of the Community Clinic Association of Los Angeles, which represents 25 free and community clinics. "These kids have no parents. They're suspicious of adults since so many of them have been abused, so they don't normally seek care. But the L.A. Free Clinic has never been afraid to tackle difficult projects, and they've taken on this one very, very successfully."
The clinic uses myriad strategies to urge reluctant kids to get the medical help they need, says Natasha Mitchnick, the Hollywood site's manager for the past six years. "Some of our psych interns go out on the street late at night to give out items like condoms, food and hygiene kits," she says. "We also have a mobile health unit, made up of two case managers and a nurse practitioner, which makes the rounds a couple of days a week to various shelters and drop-in centers. The nurse practitioner does some medical care on site, then refers the kids to the clinic for more difficult health issues."
In addition to general health care and counseling, the clinic is a sort of one-stop shopping facility, providing legal and other services such as STD and HIV testing, prenatal care and family planning. Kids who need a shower, clothes or other personal items can get them here. One corner of the clinic's bright, clean waiting room is devoted to children's books and toys that young parents can use on the spot, or cart away free. The waiting room's walls are decorated with a series of posters that are changed by the staff, depending upon the services being offered that day. Family planning is on Mondays and Wednesday, so pictures of pregnant women and cute babies are featured. On other days, the posters promote such issues as safe sex.
Whatever the decor, the mood is professional and respectful. "They actually called me 'sir,'" one highly pierced teenager said after his first visit.
From Rape to Dignity
Each young person who walks in is given what is called a "HEADSS interview (Home, Education, Activities, Drugs, Sex, and Suicide), designed to tease out the psychosocial areas of concern that a suspicious and traumatized street kid may be reluctant to mention. This helps the clinic determine who needs what service. "More often than not," Mitchnick says, "a kid comes to see us for a medical problem that's pretty minor, whereas their really serious issues - which are usually psychosocial in nature - are much harder for them to bring up."
Mitchnick tells of a youth with Fetal Alcohol Syndrome who first came to the clinic at 19. "He was this tall, stringy kid who looked like Howdy Doody, had an IQ of 71, and the most rotten set of teeth you ever saw." she says. As with many clients, the HEADSS interview indicated the boy's medical and dental problems were just the start.
"He'd been raped by his stepfather for years before being kicked out of the house," says Mitchnick. "He was living on the street where he was being victimized all over again because he was just so vulnerable." Because of his mental impediments, he didn't fare well in shelters, but he was too high functioning to qualify for a group home for the mentally disabled.
The clinic became his case manager, providing counseling and medical care, getting him on Supplemental Security Income, getting his teeth fixed, "which was really a big deal to him," Mitchnick says. "Now he's 21, living in his own apartment, and he comes back to see us all the time. ... He has a sense of dignity about himself."
The clinic has made its high-risk youth program work by partnering with other agencies, particularly Los Angeles Children's Hospital. "That partnership has been key for them," says Elizabeth Gomez, director of the Los Angeles Youth Network, a 20-bed shelter, drop-in center and case-management program aimed primarily at street youth. "It means their doctors are youth-friendly, so it's much, much less intimidating for a scared or traumatized kid to be there."
Mandy Johnson from the Community Clinic Association agrees. "It was one of the first programs in the country to combine a multidisciplinary approach with a multi-agency collaborative effort," she says. "Now that's become the national model."
Johnson adds that the clinic has taken a leadership role in forming a network of at-risk youth providers who lobby the California State Legislature for the needs of their populations. "In this day and age, you can't just provide good service, you have to also be an active advocate on a political level," says Dr. Joseph Dunn, formally the CEO of the L.A.-based Daniel Freeman hospital group, who became the clinic's executive director in February. "We lobby at both a state and local level to make sure focus is kept on the issues we see as important."
Lessons from Bad Bananas
Once the High Risk Youth Program was up and running, the clinic began branching out into other youth services, including Project ABLE (Adolescent Beliefs Learned Through Education), a peer education, theater and counseling program that sends "youth educators" to schools and lock-down facilities to conduct seminars for adolescents on subjects such as HIV and pregnancy. "Everybody knows that peer educators are one of the best ways to reach youth," says Jenny Gross, 30, the project's director.
Alex Steppling, 19, a dark-haired, intense young man with a winning smile, has been a peer educator for two years. "People open up to us in a way that I think would be more difficult with someone older," he says. "For example, if a guy is having trouble using a condom, rather than giving them clinical instruction, I explain how to make the condom part of the ritual of sex. Or I show them the little condom case on my key ring. And suddenly it's something they can handle." The peer educators make a point not to preach, Steppling says, but instead present the pros and cons of each subject in an entertaining fashion.
They put on plays on such subjects as a girl getting pressured for sex by her boyfriend. "And we have this exercise called Causes, Consequences and Alternatives of Teen Pregnancy," he says, "which is really great for letting a girl objectively examine her motives for getting pregnant. Sometimes girls are in an abusive household and having a baby is their way out. But that may not be a good motive."
At the end of each seminar, Steppling says, the students are supposed to find a creative way to show the youth educators what they've learned. At one school, Steppling says, "these guys had a video camera. And in our session about condoms, we'd used a banana to illustrate. So they made this video tape of three bananas sitting around talking. Two of them had happy faces and said they'd been using condoms. Then this rotten banana comes up and talks about how he never uses a condom, and the rotten banana fell apart.
"It was so funny. But it was great, because we knew they really got what we were trying to say."
Elvis Has Left the Clinic
Innovative programs like Project ABLE cost a good deal of money. For its first two decades, the clinic got most of its budget by poking at the conscience of L.A.'s wealthy entertainment community, which adopted the clinic as a favorite cause right from the start. In its earliest, leanest years, there were soap opera-worthy stories of this star or that saving the day - like the time in the early 1970s when the staff couldn't pay the rent until Elvis Presley walked unexpectedly through the front door with a $10,000 donation. During other money-sparse months, the Smothers Brothers stepped forward to cover rent and expenses.
In 1973, a local named Mimi West decided the clinic needed a more organized approach to its fiscal life: a fundraising arm that would allow long-range planning and budgetary projections. She founded Friends of the Free Clinic. West was married to Bernie West, a writer on "All in the Family," and lost no time in rounding up noteworthy TV and movie types who were willing to serve on a money-garnering board. Today, only one-quarter of the clinic's funding comes from its Hollywood supporters.
This now includes a younger, slightly hipper group known as The New Friends of the Free Clinic. And the celebrity stories haven't disappeared: This year, actor and former Monty Python member Eric Idle won $19,000 on Celebrity Jeopardy and donated it to the clinic.
Grants from foundations and corporations provide another one-quarter of the clinic's revenue. The remaining half is from government grants, the largest being from Los Angeles County. (The county money comes primarily from various funds in the Department of Health Services, including programs dealing with alcohol, drugs and sexually transmitted diseases.)
Partnering with the government was a step the clinic wasn't sure it wanted to take, says Dr. Susan Mandel, the clinic's medical director since 1990. "It's worked out well for us," she says. "But relying on government dollars means that more strings are attached - which also means we have more of a struggle to hold on to our mission, and our cultural origins, while hitting the marks we need to hit in order to keep our doors open."
How to Measure Success
Hitting those marks requires, among other things, constant program evaluations. "It used to be, if you had a good idea, people would give you money for this project or that project, no questions asked," says Development Director Abbe Land. "Now we have to quantify all our results." As a result, Land says, the clinic has recently hired a full time Quality Manager. "You can't just put all your resources into the programs themselves, you've got to also put them into your grant writers, your development people and your outcome research. Because these days you've got to have those evaluations when you go after dollars."
Land admits that it's especially challenging to provide concrete evaluations for behavior modification programs like Project ABLE, for which success is notoriously difficult to quantify. "We know we've been doing good work," says Project Director Gross, "but how do you measure it, other than tallying up the clients you've served?"
The clinic has several strategies. For the pregnancy prevention program, Gross says, "we pre-test the kids prior to the program starting, then post-test them ten and a half weeks later when the program is finished. After that, we hand the raw data over to researchers at the University of California, San Francisco to analyze."
Once again, partnership is the key, says Dr. Mandel, the medical director. "The California endowment gave us a grant [$246,646 over two years] to do a project with alternative therapies such as acupuncture and Chinese herbs," she says. "We turned around and gave the National Health Foundation some of those dollars to do the research that will measure the effectiveness of the program."
Outside observers clearly believe the clinics are effective. The youth programs have received awards from the likes of the United Way, the U.S. Department of Health and Human Services, Bank of America, Shell Oil, the Ryan White Foundation, the American Dental Association and the City of Los Angeles, among others. In the clinics' most recent client satisfaction survey, 92 percent of the visitors to the Beverly Center rated the services "good" or "great," while 93 percent of those showing up at the Hollywood Center for the first time said they would return or refer someone else.
The clinic is not without failures. "Recently we had to close Project STEP, our youth employment program," says Land, the development director. It turned out that jobs for high-risk youth were extremely hard to find, Land says, and funders were unwilling to be patient with the clinic's less than immediate results. "We hated to cut it, but we had to be fiscally responsible. On the other hand, you can't go around solely chasing the money at all costs.
"So we do our best to pursue grants, but only if we can do so in a way that meets the goals and mission of our agency."
These days the clinic's mission of servicing L.A.'s poor and runaway youth is facing a new challenge as gentrification spreads through Hollywood. "Now we're concerned that a lot of the kids are going underground," says Executive Director Dunn. "The police are cracking down on the young people, so the street is no longer as safe for them as it was. As a result, some of the kids are in hiding, others may be finding shelter where they're being sexually exploited."
Dunn pauses. "But we'll find a way to get them the help they need," he says, his face beaming with optimism. "That's what's so inspiring about this place. We serve most vulnerable kids in this city. ... Over and over again, we have to assess the needs of that extremely vulnerable community, then do whatever it takes to find the funds and/or a partner to meet those needs."
For free, without judgment.
Celeste Fremon can be reached at firstname.lastname@example.org