Position: Executive Director, Homeless Prenatal Program
San Francisco, Calif.
"It's not that hard. You just have to trust people and have them believe in you. What I've had in life was opportunities. Others didn't have that."—Martha Ryan, RN, MPH
"Most service providers set their boundaries and work within boundaries and limits. She's a person who feels that what she and her agency have to give should be as broad and expansive as the needs they see. She's always trying to figure out how she can do more and not less."—Ruth Brousseau, Senior Program Officer, California Wellness Foundation
"She creates a wake where people want to follow."—David Heiden, MD, Co-Worker in Somalia
The Somali desert was where Martha Ryan found the key to her life's work in San Francisco. It was 1981 and ethnic Somali nomads were streaming across the border from their villages in Ethiopia, half-starved and in many cases suffering from tuberculosis, malaria or skin ailments.
Ryan, on leave from her job as a hospital ward nurse, was working with the nonprofit Medical Volunteers International and quickly realized that the needs of the refugees far exceeded the resources of her group. "So we taught the women in the camps to be health workers. We worked with whatever we had. We knew we weren't going to be there forever."
Eight years later, after two more visits to Africa, she was working at a homeless shelter in the Haight-Ashbury section of San Francisco and starting the Homeless Prenatal Program to serve women who were pregnant and homeless. Once again, she was turning clients into outreach workers, serving them and having them reach out to others like them.
"We took an idea from the undeveloped world and brought it into the developed world," she says. "But there's an undeveloped world here in America. That's the bad news."
The program now has an annual budget of $2.5 million and serves some 2,400 families a year. It has expanded to include mental health and substance abuse services, child care, housing assistance and jail outreach. Of its staff of 41, half are former clients. In 2003, Ryan received a Robert Wood Johnson Foundation Community Health Leadership Program award.
Clients, co-workers and community leaders marvel at her ability to move easily through streets and boardrooms alike with a warm, nonjudgmental approach. For Martha Ryan, the only sin is losing hope.
"It's about providing respectful services to people who have spent their whole lives being judged," she says. "You just have to trust people and have them believe in you."
One of the believers is Carla Roberts, a former drug user who now works for Ryan in the Homeless Prenatal Program's substance abuse program. "It's amazing to have that compassion if you haven't lived the life herself," says Roberts, who is also studying for a bachelor's degree in psychology so she can become a therapist. "She doesn't look at what you've done. She looks forward to a future for you. She believes that everyone should have an opportunity."
Martha Ryan grew up with the idea of service. "I was raised with the idea of giving back," she says. Born in Quincy, Mass., the third oldest of 13 children, she spent her early years alternating between San Mateo, Calif., and Japan, where her father exported American auto parts to the Far East. "We often ate day-old bread," she recalls. "My father struggled to feed us all." Her mother volunteered in hospitals to care for American soldiers injured in the Vietnam War, and Martha knitted clothing for the poor at the Catholic school she attended.
She came back to the United States to attend college, graduating from the University of San Francisco in 1972 with a bachelor's degree in modern languages and "no clear idea of what I wanted to do with my life. I wasn't the best student in the world. So I joined the Peace Corps." Assigned to Ethiopia, she spent two years teaching English to students in the sixth through ninth grades.
"It was the Peace Corps that changed my life," she says. "That's where I got my direction." When her tour ended, she knew she wanted to return to Africa, but as a nurse rather than as a teacher. "This was something you could take anywhere in the world and something where you could give to people."
She entered a two-year nursing program at City College of San Francisco, received her AA degree, and worked at a county hospital in the medical and surgical wards and the Intensive Care Unit. In 1981, she went to Somalia, returned briefly to California, and then went back to Africa with the International Rescue Committee, this time to the Sudan, as part of a public health team near the border with Ethiopia.
"You went from dawn to dusk, building latrines, making sure water was clean," she says. "I always felt like I was in my element in these camps. I saw how people could move on as a community and grow."
Realizing that she was more interested in public health than nursing, she returned to the United States to get an MPH at the University of California at Berkeley. She didn't know it then, but her time in Africa was over.
In addition to her studies, she was doing an internship at a clinic in the Bayview-Hunter's Point section of San Francisco and volunteering at Hamilton Family Center, in the Haight-Ashbury section.
A physician at the Bayview-Hunter's Point clinic, Sandra Hernandez, MD, was amazed at her "great presence with patients. Here is this woman with red hair and freckles, about six feet tall, and she's working in a very poor African-American neighborhood," recalls Hernandez, now chief executive officer of the San Francisco Foundation. "They'd come in wheezing [from an asthmatic attack] and ask, 'Where's Martha?' We'd say, 'She's with another patient,' and they'd say, 'I'll wait.'"
"Even then, she gravitated to homeless women and pregnant teens," says Eric Goosby, MD, another internist who worked at the clinic. "In the clinic, she was a respite site for the homeless, almost a social service site."
At Hamilton Family Center, the only city-funded shelter for homeless families, there was no "almost."
"Families would go in there and grab mats and stay from 5 p.m. to 8 a.m.," Ryan recalls. "They didn't even have beds. They would find a nook and all sleep together, men, women and children in the same room. It wasn't conducive to a good night's sleep or healthy living. Some people were still using drugs, some had mental health issues. One man picked up a TV and threw it on the floor."
Faced with this seemingly endless need, Ryan decided to concentrate on one segment of the homeless population: pregnant women. "Pregnancy is a window of support, an opportunity," she says. "No woman wants to have a bad baby. It's a time to help them turn their life around."
Operating in a basement closet, she quickly learned that the hardest part of the job would not be providing prenatal care or other services—such as drug rehabilitation, housing and employment assistance—but overcoming the reluctance of the women to come to the center and accept those services.
"So I went back to my Africa stuff. In the Sudan, we had four epidemics in six months, but we were able to stem them all, not because of Western medicine but because of the women we trained who could go out there and link us to the people we could serve." Ryan used the World Health Organization's International Primary Care model. "The women in Africa had the lowest place in their society," she says, "but as community health workers they were elevated and revered. This was the chance for them to show what they could do."
The San Francisco version, of course, was quite different. "We'd go up to people's cars where we'd see them sleeping with all their belongings," says Roberts. "We'd go under the freeways."
Vennetta Coffman, a client who later became an outreach worker, remembers watching Ryan embrace a client and thinking, "The hug you give a homeless person might be the last hug they get."
In 1995, Coffman was living under a freeway off ramp in San Francisco, pregnant and subsisting on cash from recycling cans and beer bottles, when one or Ryan's workers urged her to visit the prenatal clinic.
"I kept telling them no because I smelled like beer. They kept telling me not to feel bad, that she wouldn't judge me. I was very, very surprised. I felt at ease with her when I very first met her," Coffman recalls of her initial meeting with Ryan.
Today, Coffman is working for a nonprofit housing agency and is the mother of a 10-year-old son—like Roberts, one of a series of highly successful former clients of the Homeless Prenatal Program. Another, Ramona Benson, is an outreach worker for the Black Infant Health Improvement Project in Berkeley.
Then there was the shelter client whom Ryan repeatedly—and unsuccessfully—urged to go to the Bayview-Hunters Point clinic for prenatal care.
"She finally broke down and started crying," Ryan recalls. "She said she was HIV-positive and that she never wanted to have this baby." The baby was stillborn and the mother put it in a dumpster. "She was smoking crack again," Ryan says, and was sent to the jail ward of a hospital and then to the psychiatric ward.
"Everybody had thrown in the towel and then, guess what? She's pregnant again." Ryan heard about it and sent someone from an agency that deals with HIV-positive people. "The next day she's in my office. She said, 'I can't believe you still care.'"
The woman kicked her drug habit, delivered the baby and became a community health worker in Ryan's program. "She left only when she developed full-blown AIDS and went home to die with her family," Ryan says. "She had quality at the end of her life, those last few years."
Despite some early successes, Ryan saw that good intentions alone would not take her program to the next level. Two of the more serious problems she faced were lack of funds and clients turned into outreach workers before they had kicked their drug habit. The latter challenge was handled by proceeding cautiously and tempering optimism. The funding issue was more difficult.
In 1989, Ryan was enrolled in a master's degree program in public health at the University of California at Berkeley and taking a course in grant writing. Sitting at the kitchen table of David Heiden, MD, a physician with whom she had worked in Somalia, she wrote a proposal—her first ever—to the San Francisco Foundation.
At the time, the foundation was funding fewer than 10 percent of applicants, according to Ruth Brousseau, the program officer who first reviewed Ryan's proposal. But Brousseau was "stunned" at the directness and simplicity of Ryan's story. "The authenticity of it just came through in the writing." And she was even more impressed when she saw the program in person.
"Homelessness was a new issue at the time," Brousseau says. "I felt the approaches she was taking were the types of approaches with the potential to turn people's lives around. Clients weren't treated as if they were one of a class of people that walks across the threshold and takes a number. They were seen and appreciated as individuals with skills and talents who can make a contribution to the world." The San Francisco Foundation agreed to give her $52,000 a year for three years.
The first two years of the pilot program were encouraging. In the first 10 months of 1990 and the same period in 1991, about 90 percent of the babies delivered to clients of the Homeless Prenatal Program were of normal birth weight.
By 1992, Brousseau was encouraging Ryan to seek help from larger donors. Over the next three years, with the assistance of the Robert Wood Johnson Foundation's Local Initiative Funding Partners program and other funders, she moved to larger headquarters in the city's Tenderloin district and developed a formal community health worker training program that included instruction in family planning and the prevention of sexually transmitted diseases. "We didn't want people thinking they had to get pregnant to get into the program," Ryan says.
Other services added in recent years include:
- A Substance Abuse Services program with a Jail Outreach Project, to encourage women who are incarcerated to contact the agency for services when they are released.
- A Mental Health Services program, including a full-time therapist to work with clients.
- A Housing Assistance Program that teaches clients about budgeting, credit checks and dealing with landlords. The program assists some 400 families moving into housing each year.
- An Advocacy Program, which has as its current focus helping clients seek good schools for their children, including alternative schools.
- A Safe Families program that deals with issues involving family violence and health. The program offers a support group in Spanish.
The agency is also home to a child care center and a Technology Center, where clients learn software applications and the use of e-mail and the Internet. It encourages staff members to pursue higher education, giving them up to four hours a week of paid time to do so.
The agency moved again in 2005, purchasing a three-story, 26,800-square-foot building in the Mission District.
"It's a very healing space," Ryan says. "When clients walk in, they feel great, that this is their place. One client said, 'This building reminds me of when my life was better.'"
Ryan used the $105,000 award from the Robert Wood Johnson Foundation's Community Health Leadership Program to set up a retirement fund for employees that would match contributions up to 3 percent of their salary. The staff members "were people without bank accounts, who had never thought about saving," Ryan says. Now, 97 percent of them are participating.
The agency is also engaged in a capital campaign to help finance the building. Ryan says that the Community Health Leadership award "gives you credibility with other funders."
In the future, she says, "I'd like to do after-school stuff with kids who are at risk. I'd like to figure out a way to pair high school students who are privileged with students who are not. I don't want to grow too big. I don't want to lose sight of what we're doing—providing respectful, nonjudgmental services to people who have spent their whole lives being judged.
"We're at a tipping point. We have this building, we have this recognition, we have an incredibly great staff. We already make a difference. But we could be a great model for other communities."
For more information on the Homeless Prenatal Program, see the organization's website.