Lessons from the Street Medicine Movement: 20 Years Later

    • February 10, 2011

In 1992, a compassionate Pittsburgh internist, Jim Withers, M.D., went out into the streets of his city to care for people living in alleys, parks or on sidewalks—the unsheltered homeless. With a formerly homeless friend as his partner, Withers earned the trust of his new patients, day by day, eventually founding Operation Safety Net, one of the nation’s first street medicine programs. A Robert Wood Johnson Foundation (RWJF) Community Health Leader in 2002, Withers’ work has become a model for the many street medicine programs that have developed around the world.

“Today, it’s still rare for people to offer medical services in abandoned buildings or under bridges, but there are now enough organizations for us to come together to talk about the best ways to provide this type of care,” Withers said of the annual International Street Medicine Symposium, sponsored by Operation Safety Net and Pittsburgh Mercy Health System, where Withers is an internist as well.

While homelessness has long been a part of American life, the need for street medicine grows each year. More than 3.5 million people are homeless in the United States, with numbers increasing dramatically after the recession of 2008. Every aspect of life without a home is a struggle, but attempting to maintain health while living on the street can be nearly impossible. That’s why meeting the health needs of homeless men, women and families has become the work of independent teams of physicians, nurses, medical students and volunteers.

A New Kind of Medicine

Only two 2010 Street Medicine Symposium presenters are highlighted here, but “one of the things that became clear at our meeting,” Withers said, “is that this is a new approach to health care and it’s redefining how we take care of people. It’s catching on in medical schools, along with the idea that every community should have access to street medicine.”

Working with two full-time nurses, three social workers, formerly homeless outreach workers, a psychiatrist and medical student volunteers, Withers’ teams serve people who are “often very alienated,” he explains. “Treating this population differs from other medical care situations because when we try to establish a primary care relationship, we really have to accept another person’s reality in a serious way. You must build the relationship on their terms.”

A Focus on Culturally-Sensitive Care

And Valerie Foree, winner of the Street Medicine Institute’s Innovator Award, goes the extra mile to do just that. Few people think of homelessness when strolling the picturesque beaches of Hawaii, yet Foree, a doctor of nursing practice (D.N.P)., A.P.R.N.-Rx, learned soon after coming to the island in the 1980s that the strikingly beautiful paradise has one of the highest rates of homelessness in the United States.

“Hawaii’s housing was ranked as the 10th most expensive in the nation in 2005,” Foree explains, “and the job market for well-paid jobs is very competitive. Waikiki Health Center is Hawaii’s sole recipient of federal, 330H funding for the homeless.” The Center, its mobile medical unit and two partner clinics, serve more than 28,000 people a year. “And 55 percent of our homeless population is outdoors and unsheltered,” Foree explains, noting that while the tropical climate is less harsh than a northeast winter, it is also hazardous.

“I was given the Innovator Award because I’m attempting to contribute to evidence-based research on the homeless,” said Foree, referring to her most recent work, “Fostering Culturally Sensitive Care for Hawaii’s Homeless,” originally presented at an International Transcultural Nursing Society Conference in Seattle.

When it comes to health care, Foree found that homelessness itself was more culturally relevant than Waikiki’s ethnically diverse Polynesian, Japanese, Micronesian and Native Hawaiian population. “My research shows that we need to embrace homelessness as its own unique culture and address the needs of the homeless differently,” Foree said.

“Addressing the most simple health problems requires a different approach. Say you want to treat someone with a musculoskeletal injury. That’s very common in our patients. The normal recommendation is to suggest a hot compress or heating pad every few hours. But this is a population with no consistent access to electricity or hot water, so they cannot comply. Things become even more complicated when you ask people to take medication at certain times of day or eat a healthy low-fat or low-sugar diet. These things are just not possible in the traditional way, so creative new solutions have to be explored,” Foree said. “There’s so much out here for us to learn. We have to change the way we look at homelessness.”

Training Physicians to Care for the Homeless

Teaching care providers how to serve people without shelter was the topic of Patrick Perri’s Street Medicine Symposium presentation. An internist at Massachusetts General Hospital and physician for the Boston Health Care for the Homeless Program (BHCHP), Perri, an M.D., talked about the importance of BHCHP’s newly-developed curriculum for medical care providers.

“Over the past year, we have been developing a Web-based curriculum on how to provide health care for the homeless,” Perri said. “It’s evidence-based, focuses on best practices and highlights the critical issues of caring for this population. This group has high rates of addiction, mental illness and untreated medical conditions. Even basic health problems, such as a cold, can be hard to treat,” Perri notes. “Think of how we deal with a cold. We go to bed. Someone who is homeless has to be out of the shelter at 7 a.m.—they can’t go home and get in bed.”

Their risk factors are also very different. In Boston, for example, Perri explains, “the median age of death for a homeless person living on the streets is 47, with a five-year mortality rate of more than 30 percent. You must also build trust and really hear and see people where they are. To do this well, you must be compassionate and consistent,” he said.

As one of the oldest and largest organizations providing care to the homeless, BHCHP is uniquely qualified to design such a curriculum and no one understands that better than Shaun Austin, M.D. A resident at Boston Medical Center and BHCHP volunteer, Austin explains, “I grew up living on the street, going to school from a car—struggling, on and off, like many families. By bringing care to people where they are, BHCHP helps to stabilize people who may be fearful of seeking help from institutions or who are ashamed because they are poor. Offering them care removes a tremendous barrier,” explains Austin, a National Health Services Corps scholar who intends to spend his career caring for the homeless.

“We are a sort of mobile medical home,” Perri said. “We are the same faces they see on the street, in our respite care facility and even in the hospital. We work on a primary care model, unlike some homeless health care organizations. We learned early on that homeless people die because of untreated chronic diseases, more than acute problems, so we work on preventing and managing those chronic illnesses,” explains Perri of the work of BHCHP’s doctors, psychiatrists, nurse practitioners, physician assistants and the hundreds of medical students and residents who volunteer. “We have long maintained a tradition of education and training; the curriculum is the outgrowth of that.”

An Early Investment Pays Off

The once loosely defined street medicine idea is now an accepted medical practice with support from government and private organizations. But it was not always that way. “In the 90s, the validation of the street medicine concept by the Foundation gave credibility to our nontraditional approach to care,” said Withers, referring to his Community Health Leader award and other RWJF work. “My award helped support our group and now I mentor other Community Health Leaders,” he said. The Robert Wood Johnson Foundation, along with the Pew Charitable Trust and the U.S. Conference of Mayors, funded 19 original street medicine demonstration projects in 1985. “My work continues not just because there’s a need, but because of a sense of social justice—giving care to those in need is simply the right thing to do.”

Each year, the Robert Wood Johnson Foundation selects 10 Community Health Leaders to receive an award. The winners are outstanding and otherwise unrecognized individuals who overcome daunting odds to expand access to health care and social services to underserved populations in communities across the United States. The program aims to elevate the work of these unsung heroes through enhanced recognition, technical assistance and leadership development opportunities.