LOS ANGELES — Standing on a busy street in Skid Row on a recent sunny day, Mary Marfisee tried to block out street noise as she popped her stethoscope into her ears. Dozens of people were milling about. Dogs barked. Music blared. A constant thrum of cars drove past.
But Marfisee is used to the commotion.
"I'm going to listen to your lungs and see if they're ok. Is that ok?" Marfisee asked Hermione, a nervous woman in her twenties who declined to give NPR her full name out of fear for her safety. She was pushing a stroller loaded with plastic bags, stuffed with her belongings.
Marfisee pressed the stethoscope onto the back of Hermione's oversized sweatshirt.
"Your lungs are tight," Marfisee said with concern after a few beats. "Are you having trouble breathing?" she asked.
Everything about Marfisee's approach is slow and deliberate. Before touching Hermione's arm, she hovers her hand over it and makes eye contact. Then, she lowers her hand gently. It's a deliberate, patient approach she's developed over her long career as a family medicine physician.
Hermione's worried expression relaxed. She explained that she has asthma and her inhaler was running low on medicine. She also lost her emergency EpiPen, she said. But when Marfisee offered information about a few nearby clinics that would be able to take her as a walk-in patient, Hermione turned it down.
"Maybe later. They have a bed for me at the Union Rescue Mission," Hermione said, and Marfisee's face bloomed into a smile.
That's because Marfisee, an assistant professor of medicine at UCLA, is also the family medical services director at the Union Rescue Mission. The Christian organization operates a four-story homeless shelter that is one of the oldest and largest homeless missions in Southern California. She told NPR she's coming up on 20 years tending to the more than 5,000 men, women and children who come through the doors of the shelter every year. Over that span, she's also become a recognizable figure throughout Skid Row on regular walking rounds of "street medicine" delivered to unhoused people where they are.
The interaction with Hermione is a classic example of what typically happens with her patients — both inside the mission or on city sidewalks, Marfisee said.
"Their top priority" is finding stable housing. "Their health is at the bottom of the list," she explained.
As a result, small problems, such as infections, cuts or chronic health issues often fester and become much more serious, she said.
Women experiencing homelessness face unique health challenges with few resources
Los Angeles' Skid Row is an epicenter of the homelessness crisis — not just in California, but also the nation. According to a 2025 Los Angeles Homeless Services report, an estimated 43,695 city residents were homeless at the time of an annual count of the homeless population in February. Less than half — 16,723 — live in shelters while the rest are unsheltered.
Meanwhile, a 2024 study on homelessness in Los Angeles from the nonprofit research organization RAND found that Skid Row's unsheltered population continues to skew older and female. Data also shows that this group of women has significantly lower physical and mental health than those who are sheltered, due to factors such as lack of insurance and transportation. That's particularly true for basic services such as gynecological and prenatal care.
The homeless women Marfisee works with face even more challenges than men due to a lack of services, she said.
"There are clinics on Skid Row for general health services but nothing specifically set up to address women's health needs."
Union Rescue Mission's internal studies found that about 87% of women were not up to date with their preventative pap smear or mammogram health screenings.
And when women from shelters do try to get preventative care, they're often faced with a variety of challenges. Marfisee recounted one instance in which a patient who had a family history of breast cancer was trying to schedule a mammogram. After hours of calls, Marfisee said, the earliest appointment her team was able to schedule was nine months out. Then, there were more obstacles.
"She had to come in with her proof of Medicare. Well, she not only didn't have her medical card, she'd moved from address to address, didn't even have an I.D. anymore. So we had to start that whole process," Marfisee said.
Another of her patients, a woman who had suffered from lower abdominal pains for decades, faced similar setbacks. When she wasn't in crisis mode — moving from one place to another, and in and out of shelters — the woman went from clinic to clinic seeking help, Marfisee said. But finding the root cause was difficult without consistent care from a doctor to see the case through.
It wasn't until Marfisee and her staff conducted an hours-long history that they learned she had had an IUD placed 32 years prior.
"We could correlate the pain to the birth of her daughter, who was 32 years old, and who was also [living at URM] with her," Marfisee said.
The team scoured their contacts and arranged an emergency appointment for the woman at a county hospital. That's where they confirmed that the forgotten IUD, which can last from 3 to 10 years, had never been removed and was "incarcerated into [her] lower uterine wall," Marfisee said.
She described it as a devastating and eye-opening moment that propelled her into action.
"We felt like we were doing Band-Aid women's health," Marfisee said. "We would just treat an infection or treat a problem, but not really get to the screening issues."
Potential solutions meet red tape
It lit a fire in Marfisee to provide more resources for the 150 or so women who find themselves living at the shelter at any given time. Marfisee began contacting other clinics in the area but soon realized that they were not equipped to offer those services either.
"But I'm great at research," she boasted — and dogged, too.
In December she launched the first phase of a new women's health initiative at the shelter. Alongside some medical student interns, she leads regular town halls to raise awareness about important screenings, including cervical and breast cancer check ups. They encourage the women who attend to ask questions and talk about their own health.
But it's the next phase of the initiative that Marfisee believes will make the greatest difference in these women's lives. URM has partnered with a local hospital to bring a mobile health van to the shelter twice a month. That will allow Marfisee and other volunteer physicians to offer free pap smears and mammograms to the shelter's residents. She estimates they'll be able to provide up to 100 breast exams per visit.
"One of the things that [people who work with homeless women] always say is that these women are so resilient. And I understand why they say that," she said. "But I started to rethink that because they are not really able to take care of their gynecological health needs on their own. They can't really self-treat. They need to be told that this lump that they may have been palpating in the breast is something significant."
The van could be life saving, Marfisee said. Studies show that homeless women die from breast cancer at nearly twice the rate of the general population, largely due to a lack of access to adequate care and the fact that they are more likely to be diagnosed at a later, more advanced stage of the disease.
Unfortunately, she said, the plan to provide mobile health to these women hit a few red-tape and logistical snags, and is three months behind schedule; the van driver's schedule is booked up and the shelter needs to figure out how they'll be dumping any medical waste.
Marfisee, a self-described optimist, estimates they'll overcome the challenges and begin screening patients by February.
"No matter what it takes, we'll get it done. We just have to," she said.
Meanwhile, the work continues
Back out on the street, in a small, neglected park about a block away from URM, Marfisee turns onto San Julian Street, which she calls "one of the roughest streets in the city."
There are more than a dozen adults at the park, in various states of alertness; some are in groups, others are alone. One of them is an older woman in a wheelchair. Her hands are gnarled, frozen in what looks to be a painful position.
She's got a scowl on her face as Marfisee and her students approach. But after a few minutes she warms up to them. They go over their set of screening questions: Any aches and pains? Skin issues? Cuts or bruises?
The woman's responses are quiet and mostly monosyllabic, but after a few minutes, she reaches out and takes Marfisee's hands into her own.
She's Marfisee's last street patient of the day. Heading back toward URM, Marfisee makes a note.
"Let's keep her in mind and make a note of where she hangs out, so we can follow up with her," she said.
Marfisee headed into the shelter where she'd jump right into seeing other patients. Maybe, she hoped, that might include Hermione.
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