They Just Don’t Want Help

One of the phrases that will send most healthcare for the homeless providers into a hair-on-fire-tizzy is when a justification for allowing the continuation of homelessness in our cities is based on the concept that the homeless just don’t want the help. I can understand how this line of thinking evolves.  It has been said that the United States is the richest country in the world with the most resources to help its citizens. How, then, can we explain that people are still refractory to this wealth of money and resources. The rationalization, for both society and the individual, becomes to accept that some people just don’t want the help.  It is easier for us to go about our morning commute, our jog through town or our walk into work if we work it out this way in our minds.

A few months ago, I read a book by St. Francis DeSales entitled Finding God’s Will for You. St. Francis DeSales was known for his belief that ordinary people could live holy lives in their communities and did not need to be cloistered (as in a nun) or in a monastery, cut off from the rest of the world and it’s many challenges and temptations in order to live holy lives. In this book, he talks about God’s will being the sun and ourselves or our willingness to accept his will for us as a mirror.  At times, the mirror is small and only reflects a small amount of light.  It does not mean that the sun is small but rather it is our mirror that is small.  As we grow in acceptance of God’s will, our mirror grows and is able to accept and reflect more of the sun’s light until we are fully aligned with and accepting of God’s will.  I think of our friends on the street and their willingness to accept help in the same way. When we first meet them, the mirror is small. It may even be impossible to appreciate, made small by pain, suffering, hopelessness and rejection. Feeling unloved and incapable of being loved or loving another. Many times, I have been startled at the depth of shame carried around by our fellow brothers and sisters. But over time, the mirror grows as trust is built so that one day, a full reflection is possible. An acceptance of help, hope and possibility comes into view and value is restored.

We are often impatient with this process, wanting results and success to satisfy our own needs and desires for affirmation. Building a relationship can literally take years. I once watched a brilliant lecture by a colleague from Southampton, England who called it the One-Less-F***-Off. He described a patient who, upon eye contact would yell the magical phrase that sends most people away. No matter what he said, “F*** off” was the response.  Over years, the number for f*** off’s received diminished so that once, when our colleague didn’t visit him but rather visited a nearby street friend, the patient proclaimed “Hey, where the f*** have you been”. Success defined by the most peculiar matrix. But success none-the-less.

At the June 2017 National Health Care for the Homeless Council Conference, Jim O’Connell of the Boston Healthcare for the Homeless Program responded to an audience question with a reminder that we cannot erase the trauma that has happened to our patients prior to meeting them. The growth of the person is not about us, the provider, but rather about the return of this precious individual to their rightful value as they gaze upon and accept their own reflection.

~C

The Core of Street Medicine: Peeling Back Social Justice and the Business Plan

Street Medicine has rapidly spread to become a global movement with over 100 programs worldwide on 6 continents. As the Street Medicine Institute prepares for the 13^th Annual Street Medicine Symposium this October in Allentown, PA, it’s right to explore why this movement has taken hold and how this innovative healthcare delivery plan has inspired hundreds of overworked medical providers to put on a backpack and work more long hours for free outside the traditional medical establishment. Although the explanation I put forth is in no way comprehensive, may it serve as an offering to explain the “core” of what those associated with the movement are experiencing by going to the people.

One of the first lessons taught to medical providers in their education is not to get emotionally involved in “cases.” This means not getting too close to patients—no crying, no hugs– and not experiencing what they’re experiencing. It’s become a matter of professionalism, that’s it actually UNPROFESSIONAL to care. When people come to us in the midst of some suffering, they are reduced to becoming a “case” so that we may avoid letting emotion crowd our better medical judgement. Inevitably, we come in contact with suffering and are faced with a choice. Humans without a pathological medical condition can’t meet the face of suffering and feel nothing so the choice is to either engage and take on suffering along with the patient, or disengage as a self-protective mechanism leaving the patient to suffer alone. Since the inception of our training we are taught to be professional and this means not becoming emotionally involved, the tendency is to disengage and leave the patient suffering alone.

There is no point in engaging a suffering patient unless you are suffering with them for a reason, suffering with joy. This can’t be accomplished with the goal of social justice or to fulfill a business plan. Justice depends on giving everyone his or her rightful due. This practiced in excess, especially in certain patients, can have disastrous consequences. In order to practice street medicine correctly, we must rise above justice to give everyone MORE than he is rightfully due. This is done through charity, or love.

Approaching street medicine through the lens of charity is essential because patients experiencing homelessness suffer a lot. This suffering is not just from material poverty which we can cure for a moment by offering food. They also suffer from emotional and spiritual poverty from being discarded by society; of feeling unwanted and unloved. If we are going out to cure, which as medical providers we must, then we also must engage with them in their suffering. This means not just giving medicine to relieve bodily suffering, but to cure means relieving the spiritual and emotional suffering they also carry. To accomplish this, street medicine must be approached through charity and love, not justice.

How or why has this approach to patients experiencing homelessness caught on as a global movement? Street Medicine has caught on because it’s been spread through the joy of suffering and giving through charity. This has turned the light on in traditional healthcare institutions and practitioners. When you turn a light on in a room it doesn’t just shine on the ones you love best, not just our patients, but shines on all in the room, like our colleagues and friends in the community.

Street medicine, at its core, is the light that it gives us permission to share the sufferings of our patients with joy, through charity, with the purpose of healing spiritual, emotional and bodily suffering.

~ Brett Feldman

Hesed’s Ladder

Last week, I was sitting in a leadership training about effective communication. The instructor started off with an explanation of the ladder of inference. This ladder represents stages of thinking that one goes through, often subconsciously, to determine action or inaction after observing a behavior. When we observe something, we often reflect back on the scenario to make sense of it and in doing so, may not remember all of the details (or even have all of the details). Our minds will fill in the blanks, or infer, what is missing to complete the observation so that it makes sense to us.  We determine action or inaction based on this conclusion. The example given to us was an observation of a quiet exchange between two people which concluded with one person abruptly leaving the conversation and exiting the building. We, of course, came up with a variety of colorful, and sometimes even logical, explainations for what we saw and action that should take place as a result. Sometimes this process leads to workplace drama, other times the inference ladder could be applied to whole populations resulting in dehumanizing sterotypes.

As Brett and I were talking with an old friend this week, we realized that the inference ladder had injected it’s influence on our life in a way that we did not realize until now.  I have written before about the influence of an experience Brett and I had during my PA school education at Midwestern University in which both of us spent time at Hesed House in Aurora, Il providing healthcare for the homeless. It was a meaningful experience that lead to the desire to start the DeSales Free Clinic, and eventually, LVHN Street Medicine. In our minds, Hesed House was providing comprehensive care with tons of hours of accessibility from students and volunteers. When we set out a decade ago to open the DeSales Free Clinic, we modeled it after our recollection of Hesed House. In reality, our blueprint for the vision of the DeSales Free Clinic was not Hesed House at all, but rather, the inference ladder at it’s best. A fill-in-the-blank Mad-Libs version of what we had experienced paired with what we thought was needed for the patients. Turns out inference might not always lead to poor communication or office gossip, but maybe every once in a while, a service to a population who is often dismissed as a result of the same thought process. Tricky tricky little ladder, I’m keeping my eye on you!

(Name)less

Nameless. Faceless. Invisible. It’s estimated that during the life of a homeless individual in the United States, many go up three months without being called by their name. The physical and social barriers between the housed and the unhouse are immense. For the homeless, it can seem to be an endless maze of closed doors. Like the old rat experiment from my Introduction to Psychology course- teach the rat what to do and what not to do by shocking it with a quick zap at deter unwanted behavior. For the homeless, they stand too long in the doorway of a business- zap! They go to a doctor’s office without insurance – zap! They ride the bus for too long- zap! Nowhere to go, nowhere to be and no where to feel safe.
But what happens when these souls pass on from this world? Most of the bodies of our friends who have lived their lives on the streets will remain in the county morgue waiting for someone to claim them. Usually no one comes. Unclaimed and unnoticed even after death. Most are cremated and buried in an unmarked grave, unceremoniously passing from the land of the living to the land of the dead. No memorial service, no sign in book, no slideshow of memories to cherish. Even the cause of death seem somewhat generic. The majority of the time the homeless who die on the street have died of “natural causes”. There’s no family to request an autopsy or discussion as to why or how someone died. They just simply die. The injustice against these souls does not end at the moment in which they take their last breath. Over the last 11 years, I’ve had the privilege of knowing many of our rough sleepers in the Lehigh Valley. Some have resided outside for more than a decade, others have floated between the streets, shelters and single room occupancies that scatter our cities. My experience has taught me their lives are anything but forgettable. Their survival to the moment in which they left this world is nothing short of remarkable. Many of our street friends have endured things that no human should ever experience. Abandonment, untreated mental illness, an astounding amount of physical and psychological trauma. And while each of us, homeless or housed, have undeniable autonomy over our choices, we cannot ignore how previous experiences affected growth, development and decision-making capacity of those who are unsheltered. They have taught me and those who have shared their lives with them the remarkable resilience of a person and how a community of strangers can grow to love one another when they share each other’s burdens. They are some of the funniest, kindest and truest souls I have even known who had a way of sharing their reality with me so I understood their wisdom.
As we ring in the beginning of winter this week, many cities across the United States remember those men and women who have died on our streets with a memorial service. So that their lives, even after death, can attempt to have some humanism attached to it. This year, a memorial wall has been erected in downtown Allentown. Located at 707 Hamilton St so that all who pass by will remember that the Lehigh Valley is not insulated from the harsh realities of homelessness and the fact that some of our own citizens die while struggling with homelessness. It is an attempt to remind us that we are all connected. The seen and unseen. The named and the nameless. So while we gather with those who we hold so dear during this holiday season let us remember those who passed in silence and offer them some compassion, some memory, and some honor.

Love Never Dies

In September 2016, Brett and I traveled to Rome for the canonization of Mother Teresa into sainthood. In an effort to save money, we booked a local flat through AirBNB and lodged just two blocks from the Vatican. On our way back one evening, we crossed St. Peter’s square and, after passing two armed guards stationed at a government building, made a turn onto a side street close to home. The area near the Vatican has become a safe space for the homeless to sleep at night without harassment from the police. The local homeless service providers who generously shared their time, experiences and solutions with us tell us that this is a result of Pope Francis declaring that these souls should be left alone and allowed to rest without disruption. And so, to some local surprise, the local police have backed off and allow for some peace and quiet. As such, it was no surprise to see a doorway inhabited by an elaborate cardboard-bag-bottle structure skillfully designed to block light, noise and provide an astonishing amount of concealment for the person who was likely residing somewhere inside the materials. What caught our eye, however, was an inscription scrawled on the marble slab to the left of this construction – LOVE NEVER DIES. We stopped and took a picture of this remarkable image wondering who wrote the message and if the inhabitant of this doorway agreed or disagreed with the statement. We continued onto our flat and retired for the evening. Each night, we saw the same cardboard-bag-bottle construction with the same refreshed inscription, and each night we wondered.

Three days later, we were walking back from the canonization mass. Anxious to rehydrate (it was about 92 degrees fahrenheit), use a bathroom (400am -2pm is quite a long time!) and to escape humanity for a minute (a sea of 500,000 humans is enough to make anyone need a quiet (padded) room), we nearly missed him. Our doorway dweller was awake, sitting up below the inscription and working on an elaborate drawing. Bathrooms, water and silence would have to wait. We made our way through the crowd and introduced ourselves. George, a man in his 60’s, had primarily inhabited this doorway for the last 6 years. A fisherman from Sweden, he had somehow been land ridden for some ambiguous reason. His drawings were remarkable. He had two completed charcoal drawings and was half finished with another one. All of the completed pictures contained a series of objects that were rearranged or drawn from a different angle. We explained street medicine to George and he engaged us in an interesting conversation about his experiences, affirmed that he had a doctor (however we discovered an access problem- his doctor was in Sweden), and how the heat of this summer had been particularly difficult for him. But it was his explanation of his drawings that moved me the most. The wooden truck was his favorite toy as a little boy, the canoe was his first fishing boat. A child sized fishing rod and small scaling knife were important pieces of his happy place. A pot for smoking fish lead me into a detailed conversation about how to properly prepare and cook fresh fish (fascinating for me considering I generally avoid eating things that originate from under the water). He said he draws to keep himself out of trouble. But I saw something much different. His drawings simply represented the happiest time of his life. A time when he was a young boy, falling in love with fishing and providing for himself. Before he spent 45 years at sea, had broken relationships with his family and had ended up, well, here. We purchased one of George’s drawings which hangs in a place of honor for him in our home. While he never explained why he writes his message next to his doorway everyday,  he really didn’t need to. He retains a sense of hope that one day the tides will shift and he will find his way home again, perhaps to the place in the picture.
He agreed to take a picture with us (which you can see below) and thanked us for keeping him company. As we walked away, George asked us to promise not to forget him. Promise made. Promise kept.

Waves

A few weeks ago, Lehigh Valley Health Network and the Street Medicine Program hosted two events with Dr. Jim Withers, a pioneer of street medicine in the United States, to raise awareness about homelessness to different groups in the Lehigh Valley. The first night was a small gathering of donors at a local country club with Dr. Withers as the featured panelist along with Brett and Dr. Motley, chair of the Community Health Department at Lehigh Valley Hospital.  It was a fascinating discussion about how street medicine in many cities has uncovered an ugly truth; that healthcare itself is very, very sick.  Often times the Street Medicine provider straddles two worlds. A world of middle class America and a world of extreme poverty and isolation. In terms of Maslow’s hierarchy of needs, we expect all patients to be functioning at the top of the pyramid in a place that Maslow defined as self-actualization. That is the place where people are achieving or are on their way to achieving their highest potential.  Because this is the basic assumption for all of those interacting with the healthcare system, it is no wonder that conscious or unconscious bias seeps in to our everyday patient interactions.  The traditional healthcare systems gets frustrated with those patients who just don’t or can’t follow through. We label them as non-compliant and design policies that allow us to dismiss patients from our practices after two no call no shows or after being late for an appointment a few too many times. Because after all, our clinical time is important and if we allow ‘them’ to be late then we are just enabling them.

The homeless population and their interaction with the healthcare system is an example that can be applied to many other vulnerable populations who are expected to be functioning at the tip of Maslow’s pyramid. Domestic violence, gender dysphoria, substance abuse, financial instability and recent prison release are all examples of people are struggling to have their basic needs met. It was interesting to see and talk with the attendees at the conclusion of the panel discussion. Many of them have lived in this area their entire lives and never fully understood how and why this type of human condition was lurking in their own backyards. Perhaps the best part of the evening came from the country club bartender who spoke with me, Brett and Dr. Withers after the room had mostly cleared.  He shook our hands and told us that in his job, he listens to a lot of very boring presentations (and I believe him) but he was so grateful to have listened to this panel discussion.  He felt he had learned so much and went on to tell us about the homeless people he had known in his life and how he thought they may have ended up that way. Of all the people in the room, it seemed that perhaps the unsuspecting bartender had been one of the main benefactors of the event.

The following day, Dr. Withers gave grand rounds at the Hospital. Over 200 people RSVP’d to the event and the crowd was primarily full of short and long white coats.  At the conclusion of Dr. Withers discussion, a panel of currently or formerly homeless Lehigh Valley residents shared their stories of living on the streets, surviving on the streets and in our institutions and candidly shared how things could have been better.  One panelist has been unsheltered for over 9 years and shared that the Street Medicine team are the only people he knows that are not homeless.  This spoke to me particularly as I was reminded of the isolating nature of homelessness and the sense that the world can become ‘us’ and ‘they’ with seemingly very few bridges between. As I sat and listened, I noticed how absolutely silent it was in the room.  There was not a single pager ringing, phone buzzing or hushed side-conversation. Several hundred people who usually conversate all day were hanging on every single word these brave men and women shared.  I thought about how intimidating the room must have looked from the panelist table and that for years, the patients felt like no one listened to them. And yet, here we were, begging in earnest for them to tell us their stories. The power of this paradox is in its irony. Healthcare providers have an opportunity every day to listen to our patients stories. Not just the story of their symptoms. But THEIR story. We feel pressured to rush, to ‘work lean’, to make in through but in the end, that isn’t what anyone wants. Each time I see a room full of such talent hear the message of street medicine and the stories of its patient’s, I can’t help but feel the pull of a tide. That perhaps we are closer than we think to a return to the roots of good medicine and real connections with all of our patients.

Po(o)rtland

“The woman declared that she was all for the building of a drug and alcohol rehab center next to her city apartment except that the proposed height of the building would cast shade on her kale plants and ruin her plants.”

Portland, Oregon was the host of the 2016 National Healthcare for the Homeless Conference and Policy symposium.  I found it to be a fascinating mix of liberal residual hippee mentalities mixed among upscale microbreweries.  A blue city residing in a largely rural red state. The first thing that struck me about Portland was how clean the city was. It’s beautiful to look at with its detailed architecture, Mount Hood peering over you in the background and the Willamette River hugging some of the neatest reformed parts of town. Freshly potted plants sprinkle the windowsills and front door steps of many residential and commercial properties. One afternoon I watched teams of volunteers artistically arrange flowers and potted plants in fancy designs in a local square just for the viewing pleasure of the many young professionals who eat their lunches on the squares surrounding steps. In general there was a sense of calm in the city.

But there was one obvious difference that somewhat shatters the beautiful façade of Portland. Every 6 to 10 feet I encountered a person experiencing homelessness. A man, a woman, a child just sitting on the street. Some of them were clearly high, but many of them were not. One woman sat with a pad of paper and pencil in her hand but was stuck in a catatonic state of waiting for inspiration.  Some of them were panhandling, many of them were not. Children were coloring while their parents made signs displaying their person plight. Many people were laying with their pets. The thing that struck me every day was that for the size of Portland, the number of homeless is unbelievable. Most numbers estimate between 3400-3600 people sleep on the streets of Portland every night. The lack of affordable housing and the lack of enough shelter caused the governor of Oregon to declare a state of emergency which allows homeless to sleep on the street safely without being disrupted by police, business owners or residents. The city has seemed tolerant of this and understanding of the fact that there is simply no where to shelter all of these people.  It does beg the bigger question though.  Why are there so many?

It seems that no part of the city with has been spared by number of visibly a visible homeless. During our travels, we took an informal poll. People working at donut shops. our taxicabs driver, local lifetime residents etc. We simply asked “Why do you think there are so many homeless in Portland?”   Interestingly they all gave the same answer. They thought that because Portland was such an understanding and homeless friendly community, the people (particularly youth) were seeking out Portland as a counterculture experience. There is a pervasive feeling that these that the majority of the homeless in Portland wanted to be homeless for the experience. While many of those that we informally polled recognize that the legalization of recreational marijuana probably his added to the appeal of coming to Portland, none of them could say for certain the size of that effect. The locals seem particularly bothered that there were so many people with seemingly no end in sight. While they admitted that they felt ‘bad for the people’, they were relatively unsympathetic because they felt that this was a situation that has occurred by personal choice. When I attended a breakout session with people representing homelessness from all over the state of Oregon, I told them what the locals told us about the homeless problem in Portland. I asked if they felt that it was true; that there was a counterculture experience occurring and Portland happen to be the perfect place for it to occur. All of those representing Portland on the panel adamantly denied that any of what the common feeling was true. One CEO of a local if you federally qualified health center commented that while the summers are mild, the winters are very cold and rainy and no one would choose to be homeless and stay in Portland. I would say the same for people who are homeless in New England, in Pennsylvania, in Michigan. Many people endure these harsh winters and yet they don’t leave (which has puzzled me for years). There’s no migratory patterns for the homeless to fly south for the winter. While the truth likely lies somewhere in the middle of these two polarized viewpoints, this creates a particularly large problem for philanthropy. People do not donate to a cause in which they feel the misery of poverty is by choice. Frankly, the sympathy factor goes way down and when there’s no sympathy there’s no money. Perhaps some of the most important (and challenging) steps that Portland must take is changing public perception. Porland seems prime for the picking to lead the country in inovative solutions to minimize homelessness.  A combination of finances, a youthful open minded population with well-established social and healthcare services. I look forward to watching this city’s story unfold.  Press on Portland, press on.

Nursing Notes: How Come You Never Asked?

Laura, how come you never asked me about Islam?”

I smiled at him. I said because your religion isn’t a factor for me, no one’s deserves to be homeless, especially homeless and blind.

He says to me, “I have been thinking to myself, why is this white Christian woman helping a Muslim black man” he laughs. He then lowers his head and says, “when I came to America, America was asleep. It was a beautiful country, then 9/11 happened and it became so hard for me. ” We sat in silence for less than a minute he turns to me, “Thank you, you are a great communicator and I don’t know how I would ever get here myself. God bless you. ”

Our journey together is not going to be an easy one, we are making small steps every week. Until you have become homeless or ever tried to assist the homeless you will never truly appreciate simple things such as making an appointment with a specialist, getting a pair of glasses, getting unemployment, applying for an apartment….for these people it takes months to obtain any of this. The average individual simply makes a phone call…applies online…gets the information mailed to their house…where does a homeless individual get their mail? What phone number will be called? Who has an email address?

As a nurse I don’t think I have ever felt like such a patient advocate as I do right now in my current career

Nursing Notes: “Shopping” with Love

Today I watched a woman and her boyfriend go “shopping” in our donations room….they have been wearing the same outfits for 2 weeks. They were so grateful for… everything we had to offer. I was asked several times, “can we have this?” Every time I smiled and said of course..as they sorted through the items I heard them constantly say to one another, we don’t need that, leave some of those, this is amazing…

You see this couple had a rough past, burned the bridges with their loved ones, the only bridges not burned are through current drug users. They sought out help at a rehab. When they started dating they were kicked out of rehab…tossed to the streets. All of their belongings were kept at the rehab and they have nothing.  They didn’t want to speak badly about the rehab because they felt it had truly helped them. They are now staying in a winter shelter. How do we expect people to stay clean&sober? They fought the fight of withdrawal, found support and are put to the streets. I can’t imagine how hard it would be to stay clean facing the circumstances these people have to face. It’s very sad to me…we lack support in the areas that we need it most, for the people who need it and want it..

This couple, they told me not to worry, they found love and are going to support each other through this mess. I assisted them in getting clothes, hygiene products, nail polish…just so she could feel normal again…

And thank to the person who donated the Uggs…she was ecstatic, you would have thought she won the lottery as she screamed with joy. I wish you could have seen her face.

~Laura LaCroix, R.N.

Letting In the Light

The vastness of need can seem endless.  When Brett and I started the DeSales Free Clinic, we had some experience under our collective belts to try to guide the creation of something that would be both meaningful and sustainable.  As it grew, so did our awareness about the larger problems facing the homeless population. Things like personal safety, humiliation, lack of affordable housing and lack of institutional loyalty.  It became easier to figure out reasonable treatment plans that actually had a chance of working because the context of their lives were so much clearer.

At some point, we started to become aware of the needs of other vulnerable and disenfranchised populations that were all around us. Human trafficking victims.  Domestic violence. Veterans. We learned that recently released inmates are 12.7x more likely to die within two weeks of release from prison than someone else living in their same state (Binswanger, NEJM,2007).  I still sometimes feel like a young PA student at Midwestern University all over again learning about the people that we share our world with but know very little about.  It is like standing in a dark room with the door closed. Then, someone turns on the hallway light and you see a small bit of light spread over onto your side of the carpet. Who turned on the light and who is on the other side of the door? Do you crack the door open and peak quickly? Do you fling the door open and boldly shout “Who goes there?”. Or do you retreat from the door and figure whoever turned on the light, didn’t really mean for you to see it anyway.  I think of the door as status quo.  It is always there and it is always accepted both socially and professionally. These populations often give us opportunities to engage them. They flick on the light in the hallway to see what happens to the door.  But all to often, we choose to retreat from the door and maintain the status quo.  The door never opens. Soon enough, the light turns back off and all goes back to the way it was.  But sometimes, someone flings the door wide open and invites the light in. Sometimes the door is opened by a patient. And sometimes the door is opened by a provider.  As it turns out, the light, in fact, is hope. And hope is just about the most powerful thing two people can share. A patient of Brett’s commented that he let the light in for her for the first time. Perhaps it was hope for her but little did she know that her willingness to let the light in  provides an understand that allows the light to be shared with others and the status quo to be challenged.