Salud y Comunidad (Health and Community)

By Rachel Ewing and Queen Muse

When Daphne Owen, MD, walked down the steps into the basement at the former Saint Agnes hospital in South Philadelphia for the first time more than ten years ago, she had no idea how the world she was about to enter would shape her career. 

As a young college graduate recently transplanted from California with conversational fluency in Spanish, Owen only knew she wanted to go to medical school and pursue her passion for social justice to make a difference. Those first steps would ultimately take Owen into elementary school classrooms. They’d take her to family celebrations, to waving a flag in the city’s massive Carnaval de Puebla celebrations, and to a remote mountain village outside Mexico City. They’d lead to bonds of friendship both as a physician and as a part-time bartender—all in service toward a neglected community’s health.

What she found in that basement was a then-tiny non-profit health clinic for documented and undocumented immigrants. By 2009, the Archdiocese of Philadelphia had already shut down St. Agnes Hospital, but the facility still housed physicians’ private offices. One night per week at first, these cramped quarters were also home to Puentes de Salud, or Bridges of Health. Here, Philadelphia’s Latinx immigrant families found compassionate care that was otherwise hard to come by, delivered by volunteer physicians and medical students from the Perelman School of Medicine like Owen would later become.

“I was so struck by the fact that Puentes really got it,” Owen said. “After studying sociology in college, I was interested in thinking about health from a sociological and community health standpoint, and here I’d found a place where they were already doing that work.”

That basement at St. Agnes wasn’t the clinic’s first home and it wouldn’t be the last. For the first few years after its inception in 2004, Puentes migrated from old church and hospital basements to any local health center or school that was willing to donate space. This limited Puentes volunteers to providing only the most basic preventative and primary care services. But that was all part of the vision of its founder, Steve Larson, MD: Start small, do the work, and grow once you’ve proven the value. He didn’t wait until he could afford to hire an accountant in those early days of Puentes, for instance. A shoebox full of receipts under the front seat of his truck was enough of an accounting system, to start.

Larson always envisioned more. While Owen was getting acclimated as a new volunteer helping with basic administrative tasks and checking patients in, a small group of physicians from the Hospital of the University of Pennsylvania (HUP), led by Larson, an associate professor of Emergency Medicine, were on the brink of securing a new permanent location for Puentes. The new comprehensive immigrant health and wellness center would help families with a broader array of their unmet needs—not just to be healthy, but to thrive.

Growing to Meet the Community’s Needs

In the rapidly growing Latinx immigrant community in South Philadelphia, roughly 90 percent of immigrants are undocumented and almost 100 percent live below the poverty line.

Many of the Latinx immigrants Puentes serves work in low-paying jobs, face linguistic and cultural barriers, and are at high risk of being uninsured because they have limited access to affordable coverage options. As such, many of the patients who come to Puentes have gone years without receiving even the most basic primary care, like blood pressure checks, standard vision and hearing tests, or other exams used to evaluate overall health. Volunteer physicians at Puentes have been able to help most patients reclaim their health by providing them with primary care for free or less than $20 per visit, depending on what the person can afford.

Larson hoped Puentes would become a resource for much more, though. “One of my goals was to shift Puentes from direct health care to community building and support, and education figured in prominently,” he said. Over the years, Larson and Puentes volunteers had heard countless stories from parents about their desire to help their children with homework, and their feeling that they didn’t have the language skills, or even the time, to be there for their kids and help them through their challenges with learning.

“They were voicing a need about wanting their kids to be successful in school and have a good education,” Owen said. The need for an education program was there—but not the resources or staffing.

“I couldn’t get that off the ground, though I’d tried with several Penn med students previously,” Larson said.

When Larson met Owen as a new volunteer, he saw that she could be the one to achieve this vision. Her stepfather, who is Mexican-American, is an educational leader in California, and Owen had absorbed his passion for empowering students’ success as part of her own. And she demonstrated a commitment to hard work for Puentes, showing up at health fairs and community events at a time when becoming a presence in the community was one of Larson’s primary goals. During her gap year before medical school, Owen readily took on the challenge of starting a small after-school education program for second and third graders as part of Puentes.

“Daphne is a ball of energy,” Larson said. “She’s incredibly resilient, and has a can-do attitude to achieve whatever we need. She may not know all the intricate details or how to get from point A to B, but she’ll figure it out.”

Owen needed all of those skills. The principal of Southwark Elementary with whom Larson had negotiated plans for the education program left within the year Owen was working to get it off the ground. In the school, where a majority of the students were either Southeast Asian or Latinx, many lacked proficiency in English—and all were economically disadvantaged. In the first year, Puentes didn’t have the formal paperwork to run its program inside the school, so Owen set up shop in the offices Puentes then used around the corner—another dimly lit basement, this one at a small local nonprofit, United Communities Southeast Philadelphia.

From this modest start, Hacia el Futuro, or Bridges Toward the Future, began. The program at first offered tutoring and homework assistance to 10 to 12 students once a week. In the years that followed, it has expanded, first to two days per week, and ultimately to more than 100 children who take part in educational programs four days a week—and it was only the first of what would become a suite of social and education programs for children and adults at Puentes.

A Beacon in the Community

Before Owen began medical school, Larson turned to her and said he had another job that he needed her help with. He wanted her to travel to the remote village of San Mateo Ozolco, southeast of Mexico City in the state of Puebla. Unbeknownst to most Philadelphians, San Mateo is an unofficial (and much littler) sister city. In this tiny village of 6,000 adults, at any given time, 2,000 may be living and working in Philadelphia, many of them behind the scenes of the city’s booming restaurant industry. Seeing the churn of Puentes patients who hailed from San Mateo, and who often flowed back and forth between the sister cities, Larson had begun to forge connections in the village. To understand the South Philadelphia Latinx community and their health needs, Larson realized, he needed to understand San Mateo and the socioeconomic forces that drove families across the continent seeking work.

Owen would be his “boots on the ground” to connect with the community in San Mateo. She arrived at the isolated village—high in altitude, frigid, and impoverished, to find a looking-glass miniature Philadelphia. There were families she recognized from Puentes and children walking around town in Phillies jerseys. Yet it was utterly different, too. The families lived in extreme poverty, getting by not as dishwashers and kitchen staff at urban restaurants, but through subsistence farming—many residents could eat only what they grew themselves. Owen came to understand the trauma, poverty, and struggle that drove so many to migrate north for work and opportunity, however limited.

“Daphne has this incredible capacity to build friendships,” Larson said. “She went to San Mateo, she acclimated, and she survived—and came back with the ability to give us all a deeper understanding of the social determinants that shape this community’s health. She is a real beacon for Puentes.”

Once back in Philadelphia, Owen began her medical studies at Penn. She secured a grant to hire Esther Morales to run the education program at Puentes, while she began to volunteer in clinical care.

At the same time, Owen worked part-time as a bartender to help finance her education. Ensconced in the restaurant industry where many Puentes patients work, she again found familiar faces. One night, in the wee hours, she spotted a sixteen-year-old who she’d known as a middle schooler in San Mateo. Driven north by lack of opportunity at home, he was in shock from the change from rural Mexico. In the restaurant, as in the clinic, Owen kept her eye out for him and for other San Mateo poblanos she knew.

In the clinic, she connected as a medical provider—offering as much basic care as she could, and trying to secure access to low-cost specialty care beyond the capabilities at Puentes. But for some, like Mery Martinez, a 40-year-old Honduran woman whose battle with leukemia was captured in the 2016 HBO documentary Clínica de Migrantes: life, liberty, and the pursuit of happiness, health issues had gone untreated for so long there was little left for the physicians to do.

Owen knelt beside Martinez’s wheelchair to ask her in Spanish—Would she want to be with her family? Did she know the name of the airport closest to her remote hometown in Honduras? Would she be able to manage the commute alone? Puentes volunteers pooled resources and helped Martinez spend her final days with her children. The film depicted her writhing with grief, tears welling in her eyes, as she walked with Martinez, holding her hand all the way to the boarding entry for her flight, to make sure she knew she was not alone.

Larson, Owen, and the scores of other Puentes volunteers take pride in their successes—the preventive care delivered, the diseases caught early.

Yet they are motivated by so many others like Martinez who couldn’t be saved. For Owen, it is these patients that are the driving force behind their desire to keep fighting for those that they can.

“Puentes has had a huge impact on me in terms of my thinking about the kind of doctor that I want to be,” Owen said, “and what’s possible to do with and for a community.”

When Owen graduated from the Perelman School of Medicine in 2015, soon after sending Mery Martinez on her final flight home, she chose to remain at HUP for her residency in Emergency Medicine, working alongside Larson there, as well as at Puentes. She later became the assistant medical director at Puentes, and when she completed her residency in 2019, she was offered a position among the Emergency Medicine faculty at Penn.

Whatever her role at any given time, Owen forged personal connections with members of the Latinx community. Families of children she knew for years in Hacia el Futuro invited her to celebrations across South Philadelphia. Her friends from San Mateo invited her to bear the flag in the April Carnaval parade commemorating the Battle of Puebla, year after year.

More Than a Clinic—A Model of Care

In the early days, while Owen was first working on bringing education to Puentes, Larson was working on expanding capacity. Through conversations with leaders at Penn, in 2010, Larson was allowed to use clinical space at the old Graduate Hospital (now Penn Medicine Rittenhouse). Two years later, he secured a permanent location for Puentes at 17th and South streets in an abandoned space that Penn donated.

“This is when things really started to pick up, and people began to realize that the clinic was growing in size and mission and reputation,” Larson said. “From that point on, both the University provost’s office and the health system have continued to support us, and that support has really helped us to grow.”

In the new location, the clinic extended its hours to five days a week, which allowed the team to serve more patients. And with additional resources, there was room for the educational and social programming to grow.

In addition to providing subject tutoring, Puentes now offers a broad array of educational programs to children ages 3 to 18, including computer coding and summer literacy camps to help families improve their knowledge of options for future careers and, most importantly, their health. Beyond education, Puentes also encompasses legal services, yoga, and opportunities for families that celebrate their native art and culture.

“Education and health and community wellness are all very interconnected,” Owen said—a truth that holds for both tiny rural villages like San Mateo, and the big city. “What teachers in classrooms can do for health outcomes on a larger scale is so much more than what you can do in the clinic.”

In her triple role today as assistant medical director for Puentes, and assistant professor of Emergency Medicine and director for Longitudinal Curriculum in Advocacy at the Perelman School of Medicine, Owen recruits volunteers and educates the next generation of medical students about the critical role physicians play in advocating for members of the most vulnerable and underserved populations. Penn students now represent roughly a third of all Puentes volunteers.

Other passionate members of the core staff have helped to grow Puentes in breadth and depth. Morales, who is now the clinic’s managing director, initially grew Hacia el Futuro, and helped Larson upgrade the financial system from shoebox accounting, while also expanding the clinic’s fundraising. Alexandra Wolkoff, who currently serves as the director of education, worked to increase participation and refine the Hacia el Futuro model. Under their leadership, the program has grown in complexity with an array of local college volunteers, and has expanded to include adult education programs that teach English as a Second Language and financial literacy.

The goal, as Wolkoff explained, is to build strong, trusting relationships with families and to equip them with the skills and confidence to speak and write English in everyday settings and to learn the keys to building wealth for themselves and their families.

With private fundraising and donations from Penn, in 2015, Puentes expanded its footprint in South Philadelphia, adding a new, 7,000-square-foot space to its existing Wellness Center on Penn Medicine’s Rittenhouse campus.

The dimly lit basements from Puentes’ early days are now replaced with a bright and colorful space, complete with beautiful Mexican folk art hanging daintily from the ceiling and ample room to welcome the ever-growing number of patients who continue to rely on Puentes for care.

 

Among health care providers across the country and around the globe, Puentes is recognized as a national model for immigrant health and wellness because of the team’s ability to do so much with very little—and that makes it a potential model for health care in general, where there is a clear need to help more vulnerable patients like those at Puentes without adding to the skyrocketing costs of care.

“Puentes is important for those kinds of questions,” Owen said. “For the future of health care, how do we do better by people who often are not well served by the system we have, and do it with less?”

In 2018, Owen’s Hacia el Futuro afterschool program provided 7,000 tutoring sessions for more than 125 students. In the same year, Puentes saw 8,300 clinic visits; a 30 percent increase from the year before. Near the end of 2019, Larson estimated the clinic would soon reach more than 9,000 visits. Over the years, more than 500 volunteers, including students, physicians, and other clinical providers, have put in countless hours of pro bono efforts to help the community at Puentes.

With experience, willpower, and an army of dedicated volunteers in tow, the clinic’s founders are preparing to take the Puentes model around the globe with hopes of helping other underserved communities in need of the same compassionate care.

While the vision moves forward, Larson is making plans to retire soon. He’s planning to write a book about Puentes and to spend more time painting, a longtime passion.

“I’m a full time ER doc, and I’m bad with details,” Larson said. “I’m a big-picture guy. Puentes is a beautiful thing as an artist to watch being developed. It’s very natural. We’ve never outstripped our resources, and we never overreached. It has been a steady, slow, constant growth. The more people jump into the fray and bring their gifts and skills, Daphne and Esther and Alexandra and so many others, the more the vision comes to life. Nothing I’ve experienced in my career in medicine or as an educator, in the mainframe of a traditional health system, can compare.”

Looking ahead, Larson sees tremendous potential in Owen’s character as a connector, and in her current role in the Perelman School of Medicine, to help forge new and responsible partnerships with communities in need.

“My ultimate dream is that this isn’t just something that we’re building for immigrants or people who are undocumented,” Owen said. “It’s a new way of thinking about how to do better by all of these groups that are underserved.”