Around five months ago I was on the campus of Wright State University, in Dayton, Ohio, and picked up a copy of Vital Signs, a publication of the medical school that I attend. On the front cover, one of the headlines read: “Backpack medicine.” Despite having no idea what this title meant, it resonated with me. It led me to think about my time at Ohio State studying Spanish and helping set up an outreach clinic in an underserved, predominately Hispanic trailer park. The experience working at this clinic ultimately led me to apply to medical school. I had to read the article.
It highlighted an alumnus from my medical school, Dr. Sara Doorley. It spoke about her work with the Valley Homeless Healthcare Program that she became medical director of in 2012. The article highlighted the need to serve the homeless in Santa Clara County, Calif., along with the “inherent chaos” present in Dr. Doorley’s work. It highlighted her career path, in which she took a leave from medical school to pursue medical mission work with Doctors for Global Health in El Salvador, and attended the Social Medicine Residency Program at the Albert Einstein College of Medicine/Montefiore Medical Center in the Bronx. Inspired and intrigued, I had to contact her.
So I sent an e-mail to the author of the article, who graciously connected me to Dr. Doorley. We talked on the phone about her background, my path to medical school, the Valley Homeless Healthcare Program, and a book that I had just read called “Not All of Us Are Saints” by David Hilfiker. It is a book written by a physician serving the homeless in Washington, D.C. The depth of our 20-minute conversation led to a final conclusion: I had to visit San Jose.
And so here I am, at the end of my weeklong “Social Medicine” experience with the Valley Homeless Healthcare Program. Dr. Doorley crafted my experience to give me a taste of the diverse clinics that the county program facilitates. Day one: Bill Wilson Teen Drop-In Clinic in the morning, Migrant Farmer Clinic in the evening. Day two: Medical Respite Clinic hosted at Home First homeless shelter. Day three: Suboxone Group Clinic. Day four: Gilroy Mobile Medical Unit, another rural clinic. Day five: Re-entry Mobile Medical Unit, a clinic for patients recently released from jail or prison.
To supplement my experience, Dr. Doorley recommended a book to me, “Pathologies of Power: Health, Human Rights, and the New War on the Poor,” by Paul Farmer. The main concept of the book could be summarized by this quote: “Just as the poor are more likely to fall sick and then be denied access to care, so too are they more likely to be the victims of human rights abuses, no matter how these are defined.” In the book, Farmer utilizes a term that describes the policy, culture, and human decisions that make the poor more vulnerable. He calls it “structural violence.” The book provided a great framework to analyze my experiences, which I have consolidated into three main lessons that I learned from my time with the Valley Homeless Healthcare Program, (VHHP.)
Lessons from Santa Clara County
(1) The world’s poor can live immediately next to the rich, possibly without the rich even knowing, and without either understanding the struggles the other is facing.
Such a perfect example of the growing wealth gap is shown in Santa Clara County. The budding tech wealth created by Silicon Valley located within the county has had a tremendous impact on the housing market. The website Expatistan states that monthly rent for a 900 square foot furnished accommodation in a “normal” area costs on average $2,618. The minimum wage in California is currently $10/hour. This means that a worker making minimum wage would have to work roughly 260 hours a month, or 65 hours a week, just to make enough to pay rent. Wealth inequality in San Jose is massive, and my experiences have showed me that this wealth inequality creates seemingly different realities for individuals.
“In the global era, is it wise to set, as policy goals, double standards for the rich world and the poor world, when we know that these are not different worlds but in fact the same one? Are the acrid complaints of the vulnerable necessary to remind us that they invariably see the world as one world, riven by terrible inequality and injustice?”
—Paul Farmer, Pathologies of Power
I was told that we were driving to a migrant farmer community in the southern part of the county. We were winding through a beautiful neighborhood with multi-million dollar houses. We took one sharp turn right down a dirt road, and we entered a new world. There were multiple long wooden shacks that looked similar to chicken coops, painted white, sitting low to the ground and with minimal windows. I was told that this is where the migrant farmers live while there is work. There was a fenced in area with sun-dried tomatoes as far as the eye could see. We drove to another nearby encampment, where most workers sleep in their cars, waking up at 4 a.m. to get the majority of work done before it gets too hot. Another encampment had an outhouse because there was no running water available in the living quarters. Meanwhile, a stones-throw away, there are beautiful houses with swimming pools in the backyard.
After attending a morning group therapy session focusing on addiction for residents of a respite program at the Home First homeless shelter, I was told to walk one block southeast and I would come to an area where I could find some restaurants. Leaving the facility, I wound through the groups of homeless persons coming into the facility for lunch. I dodged the stains on the sidewalk that reeked of urine and vomit. I ignored the gentleman who appeared mentally ill who was yelling an inaudible phrase at me across the street. I turned left and found groups of Hispanic men hanging outside of a Home Depot. Just a few yards further and I found myself in a suburban wonderland of restaurants, equipped with boutique sandwich joints and a Starbucks.
A patient at the Alexian Clinic in San Jose informed me that he had been off heroin for nearly 10 months thanks to Suboxone therapy. When asked about his housing, he stated that he does not make enough at his job to be able to afford rent, so he was currently looking for a second job to supplement his income. In the meantime, he was content with sleeping on the roof of his workplace that is safe because it is only accessible to employees. Only his boss is aware. He showers at a nearby gym to prepare for work every morning.
(2) Serving the poor is way more than an act of charity.
It isn’t uncommon to hear the responses, “that is so kind of you to do,” or, “those poor souls…” when you tell someone that you do work for the homeless. Although these expressions of empathy might be honest, I think that they inadvertently miss the big picture of what serving the homeless accomplishes. And it unintentionally makes the recipient of services/care appear “lesser.”
“[The poor] are those who suffer injustice. Their poverty is produced by mechanisms of impoverishment and exploitation. Their poverty is therefore an evil and an injustice.”
Hearing story after story about the lives of the patients of the Valley Homeless Healthcare Program was so empowering and humbling. One patient shared his experience growing up with a father who was a Hells Angels gang member, who insisted that his son do cocaine at the age of 10, and was murdered when he was 12 years old. He is currently receiving Suboxone treatment and often uses meth. Another story: a lesbian couple shared with me their struggle with finding a location to settle down and make a home. Originally from Germany, one of the partners had male-to-female sex reassignment surgery. They fled to the United States because they felt unsafe in their home country. Having difficulty crossing the border legally, they had to settle for traveling to multiple other countries before living in Mexico for a year. Unsatisfied with the quality of life there, they decided to cross the border into the U.S. to legally seek asylum. They are now stuck in the country without any of their official papers that were taken by U.S. customs, (they are considered flight risks,) and are now awaiting their trial to see if their request to seek asylum is approved.
Both of these stories were so deeply personal, I was honored to be hearing them. Not only do they show acts of courage within the stories themselves, but also courage in sharing the story at all. Listening to them not only gave me an appreciation for lives that are very different from my own, but they also display the concept that Paul Farmer calls structural violence. Both stories expose outside forces that have pressured individuals into living lives very different from the lives they would like to live. My experiences showed me that these forces that contribute to poverty truly are an injustice. Serving the homeless is a stance against this structural violence. It is working to preserve the human dignity and human rights that our nation stands for: freedom and liberty for all. Not charity for all.
“Once we begin to see the faces of the poor, our ‘sacrifices’ begin to feel less arduous and more intrinsically rewarding. […] When poor persons become people we know as individuals, when they are people we care about, ‘sacrifice’ is not the terrible thing it might otherwise seem.”
—David Hilfiker, Not All of Us Are Saints
Opposed to a common sentiment in the healthcare field, this experience revealed to me that serving the poor does not have to cause burnout. Every teammate of the VHHP was so positive and driven to do the work that they do. I never heard a single staff member complain about what a patient was wearing, how they smelled, how the patient “did this to themselves...” All of these are very common comments in most hospital settings that serve underserved populations. At least three of the staff physicians had been with the VHHP for 3+ years, and they all remained clearly driven to make a difference in their patients’ lives. I was truly inspired by their attitudes, and only hope that one day I can find a work environment that embraces the same values. They did not just offer medical services to their patients. They offered them understanding. They stood on the level of their patients, something much bigger than charity can offer.
(3) There are novel, cost-effective ways to serve the homeless and destitute sick.
“Efficiency cannot trump equity in the field of health and human rights.”
—Paul Farmer, Pathologies of Power
Efficiency and cost-effectiveness take the forefront for most healthcare providers. I recently received an e-mail from the Institute for Healthcare Improvement that had the subject line: “Equity: the forgotten aim?” After my experience in San Jose, I am grateful that this question is being posed. However, multiple programs offered by the VHHP are tackling both equity and efficiency head on.
I shadowed a respite care program hosted at Home First, a shelter for the homeless. The program offers 20 beds to patients who are known to be homeless and have disease processes that put them at high-risk for readmission to the hospital if they were to be discharged back to the streets. It is not cost-effective for the hospital to keep a patient admitted if his or her illness no longer requires inpatient therapy. It is also not cost-effective for the hospital to discharge a patient to the streets when their illness requires resources that the streets cannot offer, (such as a bed, ice, dressing changes, etc.) Why is it not cost-effective for the hospital to just kick these patients out the door? One word: readmission. Hospitals are now penalized through the Hospital Readmissions Reduction Program outlined in the Affordable Care Act. After speaking with Dr. Doorley, it is not surprising that this program has received funding from several hospitals in the San Jose area, and plans on expanding in the near future. Everyone wins. Better care for the patient, lower readmission rates for the hospital, more funding for the program. Equity for the patient, and efficiency for the healthcare system.
I witnessed another great example of equity with efficiency at the Re-entry Medical Clinic. Three days a week, this clinic provides medical and psychiatric services to patients recently released from jail or prison. Dr. Ari Kriegsman, another amazing physician on staff for the VHHP, recommended I read an article that was released in the NEJM in 2007 titled: “Release from Prison — A High Risk of Death for Former Inmates,” (Binswanger et al.) To summarize the findings: during the first two weeks of release, inmates are 12.7 times more likely to die compared to non-imprisoned residents. This information, coupled with overly crowded prisons and the rising costs of imprisonment for the state and federal government, explains the genius of the Re-entry Medical Clinic.
Whether a cause of homelessness or a product of homelessness, substance abuse is rampant among those living in the streets. The VHHP offers Suboxone therapy, a medication that helps patients recover from opiate addiction and does not require daily clinic visits. Every Wednesday afternoon they host the Suboxone Group Clinic. It was the most efficient and high-impact group therapy session I have witnessed. Two primary care physicians, one psychiatrist, one psychologist, one social worker, and two nurses gathered in a room and essentially evaluated ten patients simultaneously. Not only did this enable each provider to evaluate and assess how each patient was doing with his or her therapy, but it also enabled the patients to learn from each other’s experiences. Patient-provider relationships were strengthened, but so were patient-patient bonds that could provide some social structure to what is often an otherwise unstructured home life. I was struck with how simple, yet efficient, the group therapy model can be.
I am so grateful for all of the staff at the VHHP for being so eager to teach a displaced medical student from Ohio. I am especially indebted to Dr. Doorley for allowing me to be a witness of the amazing work that they do. My last experience in San Jose was a home visit with Dr. Kriegsman and staff psychologist Charles Preston. I was briefed on the ride over about the patient we were visiting. He was a patient that Dr. Kriegsman had been following for several years. A self-proclaimed gypsy, he came from a family that embraced street smarts over book smarts. He was homeless for a while, but through social work at the VHHP was placed in subsidized housing. We were making the visit because his home health aid visited him and noticed that he was confused and had a swollen face. We walked up to the door, and it was already opened. Inside I saw a bicycle, a rug, a sleeping bag, and a man sitting in a lawn chair. He had long hair and a long beard, swollen legs, and the biggest dark bags under his eyes I have ever seen. Charles was scolding him for taking half a bottle of his medications that was meant to last a month. Dr. Kriegsman was looking him over, assessing his physical signs and condition. It was in this moment, standing in a barren apartment, in a complex that smelled of weed, after driving miles away at 5 p.m. on a Friday evening, that I fully appreciated how much these men really care about their patients.
As I am writing this, a homeless gentleman is playing a wooden flute on the sidewalk just outside of the coffee shop I am working at in San Jose. He is playing a melancholy version of “Yesterday” by the Beatles. After this experience, the chorus line: “I believe in yesterday,” has new meaning. Many homeless and destitute sick are stuck living in yesterday. Social medicine meets them in the here-and-now, in the hopes that they can eventually live for a better tomorrow.