By Talya Meyers
One of the first days Dr. Pete Cathcart practiced street medicine, on a hot summer day in Nashville, wasn’t spent checking blood pressure or caring for wounds. Instead, it was about building relationships.
Carrying a “heavy” Direct Relief emergency medical kit, he and a patient navigator traveled from site to site in the heat, looking for homeless people who might need medical attention. When they finally came across an occupied encampment, they introduced themselves to the people there, paid a visit, and promised they would return.
“The next time they saw us and we came back and kept our word, they allowed us to treat them for medical issues,” he recalls.
Neighborhood Health, a community health center in Nashville where Cathcart works as a doctor, launched its street medicine program during the pandemic. The health center, like providers across the country, had moved many of its services online because of Covid-19, and its leaders quickly noticed that many homeless patients had no access to telehealth services. .
Sending a team to the streets to tend to wounds, monitor chronic illnesses and provide mental health services was one way to ensure their most vulnerable patients still received healthcare.
Today, the street medicine team includes doctors, nurse practitioners, registered nurses, a van driver and a patient escort whose role is to connect people to other services, such as housing. In addition to medicine, they bring tents and sleeping bags to distribute to homeless patients.
For Cathcart, the trust he has earned with patients living on the streets is essential. Many do not trust the medical establishment and were initially wary of doctors who showed up out of nowhere to offer help. “Now that level of confidence is there,” he said. “Our patients happily seek us out now. They even come to our clinic.”
A patient, whom Cathcart began treating for a skin infection during street medicine rounds, has now been taken in – Cathcart attested that the man’s cat was an emotional support animal – and comes to see the doctor during the clinic days.
He gained much-needed weight, Cathcart said, and is managing a long-term spinal cord injury with the help of physical therapy. “He no longer has the stressors he once had,” he said. “He looks like a different person.”
Dr Jim Withers is not the first person to practice street medicine – he credits the work of doctors like Jim O’Connell, Jack Prager and Joe Greer with inspiration and influence – but he is the one who coined the term.
“Street medicine” refers to medical care, intended primarily for homeless people, that takes place outside the walls of a clinic. “It was a nameless field of medicine, and it needed to be promoted,” Withers said.
For Withers, the need for a US-based street medicine movement became apparent while working as a doctor in Pittsburgh. Emergency services routinely called in the middle of the night, reporting patients whose unmanaged illnesses had turned into seizures. “People were sick, disconnected, traumatized,” he recalls.
As a member of the medical establishment, Withers felt like part of the problem. “I wanted to take off the white coat and be able to free myself from the structure, from the dynamics of power,” he said. “People came, and they were so traumatized that they didn’t trust you at all, and [even] with your best feelings and dreams for them, you knew you were part of the structural violence” that homeless patients regularly experience.
So, on the advice of a man named Mike, Withers began dressing in tattered clothes, rubbing dirt in his hair, and going out to hang out with homeless people. “Very quickly I realized that I couldn’t just be that watcher. I needed to heal that wound, I needed to get that blood pressure,” he recalls.
In 2008, Withers founded the Street Medicine Institute, an organization that today connects practitioners working around the world to treat homeless patients. “It’s innovative, it’s rewarding, it’s necessary, but honestly it’s a bit counter-cultural,” he said of the medicine he practices. He regularly encounters people who fear the social ramifications of practicing street medicine – or who just don’t approve.
Although unprotected people have many of the same medical issues that the general population faces — chronic illnesses, mental health issues — Withers said practicing street medicine means letting go of some of the conventions of the doctor-patient relationship.
For one thing, whatever you have in your backpack is whatever you can use, he said. On the other hand, a patient struggling with an alcohol or substance abuse disorder, or an unmanaged chronic illness, may not want to change certain behaviors. The goal is to provide them with the best possible care while understanding that their goals may be different from those of a physician.
“Street medicine is good medicine,” Withers said. “It’s the only medicine these people are going to get” if they don’t want to go to a clinic or a doctor.
Housing and health
Sometimes, said Dr. Danielle Williams, the unreliability of street medicine poses an extraordinary additional challenge.
Williams leads the street medicine team at Roots Community Health Center, a health center based in Oakland, Calif. She regularly practices primary care and treatment for mental health issues and street-based substance use disorders. But in addition, his team, like that of Cathcart, works directly to bring people to housing. His team also regularly brings food and water to unhoused patients.
For Williams, getting patients into housing — a critical factor in overall health — is a top priority. Since the pandemic, she has been able to refer a patient directly to accommodation. “Honestly, sometimes the hardest part is finding the patient and letting them know they’ve been accepted,” she said. It can also be a problem when treating substance use disorders. “I can offer suboxone, but I need to be able to find this patient on a regular basis, and I haven’t seen that happen,” she said.
She explained that keeping track of medications can be difficult for many of her patients. Many have back problems or arthritis “because of such a difficult life”.
“I think focusing on housing is more important,” she said.
The delicate balance between meeting immediate needs and creating a healthier future for a homeless patient is something that street medicine practitioners regularly face, Withers said. Many have a “hidden agenda” to place patients in regular, high-quality housing and primary care, but they understand the need to meet patients where they are rather than dictating a care pathway.
It’s important to be aware that many homeless patients “are tired of more people taking over from them,” he explained. That’s why the work of doctors like Williams, Withers and Cathcart, who build trust with their patients, treat them appropriately and listen to their needs, is so essential.
“It’s like harm reduction. You’re going to build the best relationships when you just respect people,” Withers said.
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