The family arrives at the poorly maintained trailer where the clinic is housed. As Perfecto shuts off the car, he notices the gas gauge is hovering on empty. The family sits quietly in the car until Estrella steps out.
Earlier that day the family struggled in vein to free their car from a patch of mud. Finally a truck of laborers saw them struggling and stopped to help. Together the men pushed the car out of the drying mud for the grateful family.
As they enter the clinic, Perfecto notes broken things he could fix in exchange for service. Estrella helps the weak Alejo sit down inside, while the family waits for someone to arrive. The clinic is empty, but a car parked in front signals that someone should be returning shortly. The twins begin looking at all the medical equipment, while Petra grows increasingly nervous about what they will be asked to pay. She looks with suspicion at a scale like the one used to measure crops at the end of the workday.
A young woman wearing red lipstick and carnation perfume enters the clinic. She is surprised to find people waiting and repeatedly checks her watch, annoyed. Estrella becomes aware of how dirty her own clothes are. The nurse begins to ask Estrella questions about Alejo; she lies both about his age and his relationship to her. At the nurse’s request Alejo weakly stands to be weighed. Watching the scene, Estrella concludes that she cannot rely on God, only herself. She helps Alejo lay down on the examining table, where the nurse measures his blood pressure and temperature.
Petra watches the nurse with disdain; she distrusts the nurse’s synthetic perfume and carefully arranged desk. Estrella disappears behind a curtain with the nurse and Alejo. Petra wonders aloud how much the visit will cost but receives no answer.
The nurse informs Estrella that Alejo likely has dysentery and should be taken to the hospital in Corazon. Petra and Perfecto argue that it is not their responsibility to continue caring for Alejo. Hurt, Estrella reminds Perfecto of their bargain about the barn and insists they take him.
The nurse charges the family ten dollars—five less than the standard price—for the visit. Perfecto only has $9.07 in his wallet. Estrella attempts to barter Perfecto’s service as she realizes they will need all their remaining money to buy gasoline for the trip to the hospital. The nurse refuses to accept any work, saying the $9.07 can cover the visit. Annoyed, the nurse tells Estrella she must pick up her sons soon. Estrella panics, realizing she must keep the money to save Alejo. In a moment of clarity, she realizes that the family’s labor makes the nurse’s middle class life possible. Energized she concludes that “the nurse owed them as much as they owed her” (148).
The family walks out defeated. Estrella runs to the car for Perfecto’s crowbar; as she turns back towards the clinic, everyone follows her inside. Estrella demands her money back from a terrified nurse. When the nurse doesn’t react, she slams the crowbar on the counter, breaking the woman’s family photos and cutesy figurine. Trembling, the nurse spills all the money in the lockbox on the counter. Estrella takes precisely 9.07$, showing the nurse she just wants her money back. She feels as if she has two personalities.
The family buys gasoline at a nearby station before heading for the hospital. Alejo questions Estrella’s actions, wanting to know if she hurt the nurse. Estrella explains she was forced to act, disappointed that Alejo hasn’t understood her sacrifice for him. She remembers seeing a beautiful grocery store display of bell peppers ruined when a woman plucked one from the top of the pyramid. Alejo worries that Estrella has played into a stereotype.
Perfecto talks with Petra, lying yet again about his intention to stay. He takes the exit for the hospital and drives through a dangerous neighborhood. When the car pulls up, Perfecto tells Estrella to leave Alejo in the hospital. Estrella thanks Perfecto before dragging a stumbling Alejo into the hospital. When she exits the hospital she walks through a pair of automatic glass doors. From the back seat the twin girls see their older sister miraculously parting glass.
In Part IV Estrella emerges as a true leader. When the family sits paralyzed in the car in front of the clinic, Estrella is the first to emerge (134). When they enter the empty trailer, she insists they wait (135). Likewise, Estrella decides she will take Alejo to the hospital (142) and use violence to secure gas money (149). As she returns to the clinic with her weapon, Estrella’s family quietly falls in behind her (149). As Estrella’s leadership emerges, God’s leadership is markedly absent. After watching the sick Alejo, she concludes that “God was mean and did not care and she was alone to fend for herself” (139). Later she notes the absence of God’s help (147). It is not God who makes things happen, but Estrella and her crowbar. At the end of Part IV this transfer of responsibility is complete. Her sisters see Estrella parting glass doors like Moses parted the sea (156). Estrella has her own powers; our protagonist has no need for a traditional Christian God.
Throughout Part IV, the family demonstrates their deep discomfort with the clinic. Estrella lies to the nurse, feeling she may be denied help if she admits Alejo is not a family member (138). She confirms that the whole experience is “unsettling” (139). Likewise, during the visit Petra and Perfecto “[watch] nervously from the sidelines,” unsure of how to act (140). The family doesn’t understand clinic protocol, feeling out of place and vulnerable. The nurse’s meticulous uniform makes Estrella self-conscious of her own dirty clothing (137). Moreover, the nurse’s treatment is less than compassionate, and even dehumanizing. Lying on the examining table, Alejo is “like a slab of beef on butcher paper” (140). The misunderstandings extend into economics. The cost of the visit strikes the family as shocking; they don’t understand what the nurse has done to deserve all their money (144). When Perfecto attempts to barter his services, the nurse insists the clinic can only accept cash (145); the family and establishment are functioning on different economies entirely.
The clinic nurse represents the American middle class, which happily ignores the sacrifices and labor of the marginal migrant laborers. She is defined in the narrative by middle-class objects. The nurse wears red lipstick and carnation perfume (137); her desk is crowded with figurines and framed pictures (141). When inconvenienced by the family, she becomes resentful (147). Like the vast majority of middle- and upper-class Americans, the nurse does not consider that the family’s hard labor makes her comfortable life possible. She is not an evil figure; she accepts the family’s $9.07, when the standard fee is $15 (145). Yet she does not have the moral imagination to realize that as a member of the middle class she profits from the oppression of marginalized groups. By the end of her encounter with the family her “perfect” (149) lipstick is “smeared” (150); the objects on her desk have been shattered (149). By asserting herself, Estrella has disordered her middle-class world.
The medical scale reminds Petra of having her labor weighed in the fields, an exploitative practice (136). Indeed, Viramontes depicts the clinic as another uncaring authority. When Estrella tells Perfecto the price of the visit, Petra is reminded of someone “surrender[ing] to the police or La Migra” (144). The family is being coerced by a system blind to their sacrifices and pain. Estrella realizes the fundamental unfairness of being charged at the clinic when she realizes her labor underwrites the nurse’s middle-class existence (148). In her mind, the nurse and, more broadly, society owe her for her labor. By changing the story—she does not owe them, they owe her—Estrella is empowered to act. She strategically employs violence to make herself noticed. As she explains afterwards, the nurse ignored her words; only the crowbar could secure Alejo’s life (151). Estrella understands action and even violence were necessary in order to assure justice.
If Estrella understands the importance of action, Alejo and her family do not. Petra and Perfecto are afraid of taking Alejo to the hospital, arguing that he is not their responsibility (142). Both are waiting for another to act, as they don’t feel they have the capacity to do so. Even Alejo cannot imagine actually going to the hospital; he asks Estrella to take him home (145). After she takes definitive action to save his life, Alejo does not understand her sacrifice, frustrating her (152). He, like her family and many others, has resigned himself to what he views as fate. Indeed, he claims he is not worth her sacrifice (152). Alejo has bought into a repressive system that views him as basically worthless. Estrella rejects this system, finding value in herself and other workers. Moreover she is willing to act, violently if necessary, to protect this value.