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I remember the first few times as a child seeing homeless people on the cold streets of Toronto. For a long time I thought that homelessness was simply a city thing. Whenever my family traveled south to the “big city” and walked the streets, I would see these people lying on the sidewalks on top of the city grates, or by the subway entrances and exits, holding out cups with some small change in them. For the small town kid that I was, these people were as iconic to me as the CN Tower. I believed this up until the day when one homeless man started hanging around my hometown, a small community of 1400 people. This event stuck with me: It was then that I realized that homelessness was not just a city problem—it was a community problem.
When I started medical school I was lucky to become involved with a group of upper-year students doing outreach and providing medical care to homeless persons in a clinic in downtown Detroit. It was here that I got my first real experience helping this population. Operating out of a warming shelter, a team consisting of a nurse practitioner and medical students, with the occasional physician and resident, open their clinic doors to homeless people residing there. I remember first learning that the average life expectancy of a homeless person is estimated from 42 to 52 years—in other words, about what it was in the United States at the start of the 1900s. This is the unfortunate reality of being homeless and the dangers of such extreme social exclusion. This is what tremendous physical and psychological stressors, in the form of the natural elements; infectious disease; malnutrition; and most unfortunately, other humans, does to the human body. This is when I knew something more had to be done.
As young medical students in the clinic, the pathology we were seeing was astonishing, exciting, and scary. I clearly remember the look of a second-year medical student as he was removing the staples that adorned the head of a man who previously left the hospital AMA, and then removing and cleaning out the PICC line that was still in place for who knows how long. It is a ripe training ground. I have experienced many firsts there. My first case of trench foot, first HIV-positive patient, first lung tap, first patient walking out halfway through her encounter with me, and the list goes on. In all of this excitement I can understand how easy it is to lose sight of the real importance of the work we are doing and turn the focus inward to ourselves. I have seen too many well-meaning poster presentations praising street medicine as a teaching tool for students. And while it may be a great opportunity to learn, it is a better opportunity to do good. These are sick people who need our help.
To paraphrase Dr. Jim Withers (the father of street medicine): Whenever you see people, or the medical profession, pushing away a specific group of people, or talking badly about them and ignoring them, you must go to those people. He says it much more eloquently than I do, but that's the spirit of street medicine: meeting people where they are. I think every medical student is taught to sit down with their patient and talk with them. When that same idea is applied to homeless persons, the result is similar. You have to level with people, you have to go to them and go into their homes, or crouch down with them street-side. You have to earn their trust so that they can let you into their lives.
People like to use the term “the homeless”; however, in reality they are not a homogeneous group. During discussions of street medicine people too often comment, “Wow, so you must see a lot of substance abuse and psychiatric problems.” Of course we see those—I see them in the family practice office every day, too. There are over 17 million alcoholics in the United States, and visits containing a psychiatric component make up about 20% of all visits to the primary care physician. I often tell the students, and other people interested in the work we do, not to forget that people that are homeless suffer from “regular” (I stress how silly it sounds to say) conditions, too.
And while the reasons for vising the street clinic are diverse, the reasons for homelessness are even more so. Part of our work includes tracking down homeless people who are “resource-resistant.” Often they are people who prefer to stay out of the system. Unfortunately, the cause of this resistance is too often iatrogenic, or maybe more accurately, communogenic. They prefer to stay out of the shelters because they are dangerous or dirty, they prefer to stay out of social security or housing programs because they perceived as untrustworthy, they even prefer to stay out of the hospital due to prior mistreatment (medical or social). It stems from bad experiences coupled with their own medical history and complexities. These are the shunned members of society. They need our help. I encourage every young medical student to reach out to potential community partners and try to get involved in this type of work. There is much to learn and much more good to be done.
Back to the October 2017 issue of ACP IMpact