With the click of a metal latch, the security guard snaps open the iron gate leading into the hallway of one of downtown LA’s many single resident occupancy (SRO) hotels. I have arrived here on an early Tuesday morning with Erika Goff, a district public health nurse with the Los Angeles County Department of Health Services. We have come to this hotel to track down a resident potentially infected with tuberculosis.

As we enter the dark corridor, light bulbs flicker overhead and the muffled sounds of music and voices waft from behind shuttered doors. In the narrow stairway, three residents light cigarettes from a single match and eye us suspiciously as we pass. At the top of the stairs, an open window faces out onto a brick wall. The carpets are stained a pallid gray. One young woman, dazed and gaunt, stumbles past us towards the stairs, while two others linger at the door to the floor’s only bathroom. "I used to not come into this hotel by myself," Goff confides, "but I’ve gotten used to it."

We stop at the end of the hall and Goff knocks loudly on the door of one of the rooms. A frail black woman, aged well beyond her years, appears from around the corner and informs us that the occupant has just left. Goff knocks one more time and, after another moment of no response, we retrace our steps to the lobby. She hands an envelope to the hotel manager to give to the resident. The envelope contains an appointment card for a chest x-ray at the local county satellite clinic.

Such living conditions are typical of those that Goff encounters on a daily basis in the course of her work. Goff is one of four district public health nurses assigned to the Skid Row area of downtown. These nurses, along with about 170 others throughout the county, are responsible for, among other things, investigating reported cases of communicable diseases and tracking down individuals with whom they might have come in contact. We step out onto the street, where the bright morning sun stings our eyes and heats the pavement below our feet. The day is already warm and the sidewalk is teeming with people and tents and shopping carts. We jump into her car parked in front of the hotel; we have more contacts to track down before the morning is through.

District public health nurses form the county’s frontline of infectious disease control. Unlike nurses in hospitals or clinic settings, these nurses work on the streets, in patients’ homes, and in the community. They serve all at once as detectives, educators, social workers, and health care providers. It’s a difficult job for any professional, but no more so than for the team of nurses assigned to LA’s Skid Row—an area with one of the highest concentration of homeless anywhere in the country.

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The efforts of nurses such as Goff are part of a long public health tradition dating back to the mid-1800s, when techniques were first devised to control the explosion of infectious diseases in the working-class urban tenements of Europe and America. The methods are simple and have changed little in the past two centuries: create a reporting system for all cases of infection, identify individuals who become infected, provide treatment (or isolation for those that pose a more serious threat) and, in cases of diseases that are easily spread from person to person, track down close contacts before the diseases have an opportunity to spread. Such techniques require little by way of advanced technology, medical or otherwise, but they do require a dedicated team of experienced professionals.

In Los Angeles, as in all other major cities, current law mandates that all health care providers report cases of communicable diseases to county health officials. The list of reportable diseases in LA County number 80, ranging from AIDS to anthrax, syphilis to SARS. Depending upon the nature of the disease and the likelihood of contagion, reporting requirements vary in their urgency: some diseases may be reported by mail within a week, while more serious conditions must be reported immediately or within 24 hours of diagnosis. Once a disease has been reported, district public health nurses are assigned to the case, to identify a source of infection, ensure that individuals receive proper treatment, and find any others with whom the source may have come in contact. District public health nursing is not confined to Skid Row, but the magnitude of the challenges that the nurses who work in this neighborhood face is unparalleled. Goff and her colleagues respond to nearly 200 referrals each year within the half-square-mile district. The rates of tuberculosis, hepatitis, HIV, chlamydia, syphilis and a litany of other diseases in Skid Row are many times higher than the county average. Certain illnesses that surface here are unlikely to appear anywhere else in the region. In addition, the transient nature of the area’s massive homeless population adds to the challenge of finding and tracking individuals. Soaring rates of mental illness and substance abuse pose yet more obstacles to health education and treatment efforts. These nurses face a veritable mountain of communicable disease, with limited resources to slow its spread.

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Standing on the corner of 6th and San Pedro, it’s not difficult to see why Skid Row produces such high rates of illness. Sidewalk living conditions, lack of proper hygiene facilities, poor sanitation, and questionable sources of food—not to mention short supplies of clean needles and condoms—all conspire against the good intentions of Goff and her colleagues. Add overcrowded conditions in local shelters and painfully understaffed clinics to the mix and the enormity of Goff’s task starts to become apparent.

Goff, 34, is an energetic woman with a determined walk and a ready smile. On the day I accompany her, she wears her county identification badge around her neck and a straw hat with a wide floppy brim. "I’ve worked as a public health nurse in this neighborhood for four and a half years," she says. "I used to say I wouldn’t work on Skid Row, but now it doesn’t bother me. I really feel for the people here." As we make our way along the busy streets, she frequently interrupts our discussion to look into the eyes of men and women we pass and extend a friendly greeting. (Such niceties, I later learn, are as much a courtesy as a safety precaution for these nurses, who often work alone or only in pairs.) She says that the challenges of working with a population so much in need offers her a sense of purpose and allows her to feel she is doing something worthwhile.

We make a quick stop into the county’s public health satellite clinic to drop off some paperwork, then head out to investigate another potential TB contact. The address turns out to be a business. We enter the lobby of an old office building and wait for the elevator as morning workers scurry past. The elevator doors open and we crowd in next to a man pushing a cart full of discarded fabric. A Latino man operates the old-fashioned lift by hand. We swallow hard as he turns the metal lever and the car pulls away from the lobby.

We arrive at the designated floor and find ourselves in a corridor lined with entries into small garment workshops. Our address takes us to the entrance of one shop, Goff asks for the woman in question by name and the woman we seek emerges from a back room. Goff tries to explain that she needs to come to the clinic to receive testing. The woman speaks only Spanish, Goff’s command of the language is limited, but the woman seems to understand. Goff extends an appointment card and confirms the information with the woman’s husband before leaving.

For certain communicable diseases, health care providers may report not only personal information for the patient diagnosed—the index card—but also for individuals with whom the patient has had close contact. Contacts may include spouses and children, other household members, co-workers, and/or sexual partners. In most cases, the contacts at highest risk are required to be tested as well. This is where district public health nurses come in —ensuring not only that index cases receive preventive education and proper treatment, but also that any additional contacts are identified and tested as well.

In the best-case scenarios for the nurses on Skid Row, clients will have an address where they can be reached. "We may get addresses from the hospital, or from TB control, or from providers in another state who first diagnosed the case," explains Goff. They may be addresses of local SROs or they may be work addresses. However, as often as not, among the Skid Row clientele, addresses turn out to be false or out-of-date. In such situations, the nurses next try to locate the individuals through one of the area’s many homeless shelters and social service agencies.
In the most difficult cases, the nurses receive little more than a street corner where an individual is known to hang out. "We’ll receive a client’s address as homeless on 6th and San Pedro," says Alejandra Novelo, Public Nursing Supervisor for the Skid Row team. In such cases, the nurses may ask around on the streets to try to track the person down. "Even though the population is transient, there is often some stability that we can count on."

Timing is also an important factor in finding individuals. "The first of the month is difficult," Goff explains, "because many people receive support checks from the government and will rent a hotel room somewhere until the money runs out." Even the time of day can make a difference. Goff says that she often makes field visits in the mornings, because traffic in downtown is lighter then. It is easier to find people in the early hours, before the police sweeps force people and their belongings off the streets.

The challenges do not end once a client is found. As our encounter in the garment workshop suggests, language is often a barrier—one that concerns district public health nurses throughout LA. Goff says that in her years on the job, she has encountered patients who speak Spanish, Korean, Chinese, Japanese, and Amharic, a language native to Ethiopia. While several nurses do speak languages other than English, most, like Goff, carry cell phones so they can use translation services, such as AT&T’s Language Line, to communicate the more complex information to their patients.
Perhaps most challenging of all are the health and social issues that inevitably accompany the communicable diseases. "In any district, it’s rare not to find clients with other medical or socioeconomic issues," says Novelo, "but in Skid Row, we find many issues with every client." Substance abuse, mental illness, domestic violence, and movement in and out of jail often make compliance with testing or treatment requirements difficult to follow. "We have to be social workers as well as nurses."

Goff’s own efforts reflect the multiple roles that she and her colleagues must play. She tells me of one recent client whose only pair of shoes was in tatters; she carries a gift certificate to a local shoe outlet to give him the next time they cross paths. Sometimes she brings individuals birthday cakes, small gifts, or other tokens—as incentives for sticking to their treatment regimens. During the holidays, she and the other Skid Row nurses collect donations at their office to put together care packages of soap, toothbrushes, socks, and food items for their clients. All of the Skid Row nurses can tell stories of their efforts to find individuals housing, jobs, substance abuse treatment, and even haircuts. As these nurses understand only too well, success on their job requires treating not just the disease, but the whole person—however meager that assistance may seem.

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While district public health nurses are responsible for tracking a wide range of conditions, by far the most common disease nurses face on Skid Row is tuberculosis. Rates of the disease in Los Angeles County are notoriously high, particularly among the poor. While the disease can be treated, it requires adherence to a minimum six-month regimen of pills. Sticking to the treatment is difficult for them, particularly for individuals with no permanent housing, significant mental health or substance abuse problems, or literacy levels that make it difficult to even read a calendar. And the spread of multiple drug-resistant strains of TB in recent years has added a further complicating twist to efforts to slow the spread of the endemic disease.

For its part, the Department of Health Services has devoted substantial resources to increase adherence to TB treatment among the homeless of Skid Row. Patients can receive their medications each day at the county’s satellite clinic through a procedure called "directly observed therapy." Those undergoing treatment are eligible for food vouchers and subsidized rent in certain approved SROs in the area. Unfortunately, such benefits run out as soon as treatment ends. While clients do get referrals for permanent housing and other resources at the beginning of their treatment, at the end, they often find themselves back in the same vulnerable situations in which they began.
While tuberculosis is a relatively difficult disease to catch, the circumstances on Skid Row—particularly in the area’s overcrowded shelters —provide ideal conditions for the disease to spread. If an active case of TB is traced to a shelter, the nurses try to identify others who might have been exposed. "We want to know which beds people slept in," explains Marisol Fortades, another of the district public health nurses working in the area. "We want to know which nights they were there, who was sleeping in adjacent beds, whether the bed was near a window, what the ventilation and lighting was like in the room. Using this information, we try to determine high-risk and low-risk contacts." But knowing this information is one thing. Finding the individuals in question is another thing entirely. Individuals are likely to vanish after a night or two in a shelter, just as quickly as they appeared. "It truly is like searching for a needle in a haystack."

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Goff and I visit a few more addresses, then double back to the Union Rescue Mission at 6th and San Pedro. On the surrounding streets, LAPD officers have begun to clear the sidewalks of tents and belongings and issue citations for loitering. Such sweeps have been one of Police Chief William Bratton’s main strategies for transforming Skid Row into a neighborhood fit for middle-class residents and the services catering to them.
The nurses are certainly aware of the influx of new residents to the neighborhood. "I have had contact with some career people in downtown," Goff says, referring to the residents of the area’s many new and converted lofts, "but most of them I treat for food-borne diseases. They are artists and engineers and business people, and they eat all over town." While most food-borne illnesses require a 24-hour response—sometimes calling for Goff to work on weekends—such diseases are far easier to treat than the intractable conditions that plague the district’s homeless residents.

Indeed, when asked directly about recent changes they’ve seen in the neighborhood, Goff and her colleagues are quick to point not to the area’s growing population of loft dwellers, but to something much more directly impacting their work: increasing numbers of women and children on the streets. Such developments are troubling, suggesting that the safety net that once protected women and children from the harshest effects of poverty may no longer be working.

Inside the Union Rescue Mission, the women’s day room is filled with women of all ages. They are waiting to see a provider in one of the mission’s overstretched clinics or simply passing the time watching daytime soap operas on television screens overhead. A striking number of children are also present. One young boy entertains himself by spinning a nickel on the concrete floor. The walls of the room are decorated with health education posters, warning of the signs and symptoms of tuberculosis, and encouraging individuals to get tested.

I explore the main lobby of the mission while Goff speaks with nurses in one of the clinics. Next to the women’s day room is a chapel with a vaulted ceiling and folding chairs. Through the glass doors, I can see a black preacher in a neatly pressed suit offering a passionate sermon, arms spread wide, to a room full of congregants. The walls of the chapel are painted a pristine white and light pours in through stained-glass windows high above.

Back in her car outside the mission, Goff offers to explain why she chose public health nursing as a profession. "I had been training for the intensive care unit," she begins. "I came home one day and found that my father had coded." Coded? "He’d had a heart attack. I rode with him in the ambulance to the hospital, and I knew he wouldn’t be coming home. I understood why he’d gotten sick: the stigmas of living as a black man, of not going to the doctor, of being poor in Oklahoma had all added up in his life. That was July 2001 when he passed away. It was then I decided that I needed to be on the other side of the spectrum—to do something to prevent disease, to teach people about health, to talk to them, to educate them. If I could have done something for my father before he passed away, maybe I could have prevented his death."

Kevin Riley is a freelance writer and a graduate student in sociology at UCLA. He can be reached at .