A Tale of Three Cities

By: Paul Gil, DWW-SBSM Communications Student Team Leader 

Bundled up in my sweatshirt and peacoat, I walk down Newbury Street in a small group of Doctors Without Walls volunteers. It is 6:45 in the morning and the sidewalks are already alive with the hustle and bustle of the city. Colossal towers watch over us as we make our way through their streets and each gust of wind reminds me that I was spoiled growing up in one of the world’s most accommodating climates. This isn’t Santa Barbara anymore.

Despite the frigid air, I couldn’t be happier to be making this morning trek. We are at the 9th Annual International Street Medicine Symposium in Boston, and before the conference convenes for its Saturday session, I, along with Zoe Teton, Sean Nguyen, and Kelly Pineda, have the opportunity to pick the brains of three inspirational street medicine minds.

We stroll into Starbucks to find Dr. Jason Prystowsky, Medical Director of Doctors Without Walls, and Dr. Jim Withers, the founder of the Street Medicine Institute and Operation Safety Net, waiting for us. Everyone grabs coffee and takes a seat around the haphazardly assembled group of tables. Next in is Dr. Jose Vargas Vidot (also known as “Dr Chaco”), Executive Director of Iniciativa Communitaria, who is attending the symposium from Puerto Rico. He is soon followed by Harsh Mander, Director of Aman Biradari and Centre of Equity Studies, who hails from Delhi, India.

Conversation begins with a disclaimer from Dr. Withers that the coffee has yet to kick in and leads into a discussion of the message behind street medicine, mediated by Dr. Prystowsky.

In an attempt to fully convey the lessons of this interview, it is transcribed in full below.

Dr. Prystowsky: “So the question for Jim was, what do you see as the message of the street medicine movement and what has it been like being on the American ground floor of street medicine and watching grow and develop to what it is today?”

Dr. Withers: “Well I think street medicine finds a diverse number of people; good, compassionate, honest people, who are beginning to explore the basic values and actions of health care. In that journey, we are beginning to find that going to where people are in a humble way, seeing their value, and finding common ground with them is beginning to transform how many of us look at health care and ourselves in relationship to others. The streets are a type of environment that is very poignant. There is a great need on the streets, which are also an amazing classroom for social justice and creative community building. Even though this is a necessary medical activity, I think it actually represents a transformative movement. This is why I think it connects with so many types of people across the planet; because the core meaning of it is something we can embrace.

There is a spontaneous awareness. We are clearly at a point where many people around the world are finding that we need to find deeper meaning about how we treat each other and in the process, find who we are as well. It has the potential of transforming the systems which are currently in place in a positive way. I don’t have the allusion that we are going to change the fundamental structure of unjust and selfish organizations. I think you have to start outside of the mess and start with new principles, like those of street medicine. Then people will look and say, ‘These people are having a lot more fun than I am. They are living their lives. What do they have and how do I get some?’”

Dr. Withers first began practicing in the streets by dressing up like he was homeless and making his way under the bridges and into the back alleys of Pittsburgh, meeting the most vulnerable where they were at. What Dr. Withers started caught the attention of others, who latched onto the idea and grew it into Operation Safety Net, one of the nation’s first street medicine programs. It now provides medical outreach, housing and case management, education for students, and much more.

In an effort to bring together those with the same motivations, Dr. Withers founded the International Street Medicine Symposium, and not much after, the Street Medicine Institute. Nine years later, we found ourselves in conversation with him about the state of street medicine around the world.

Dr. Prystowsky: “So this is a perfect opportunity because now we can talk about street medicine as a movement, as individuals, and also, how we adapt to our different locations; Delhi, Pittsburgh, and Puerto Rico.”

Dr. Vargas: “I think that as Jim established, there are a lot people doing the same work and they don’t need us to organize them because it’s a movement that comes from the manifestation of the human being. It’s a revolution that starts at the heart. You don’t need any training. You just need to open you heart and start listening. When I met Jim, I started to realize that it is really important to organize people with common philosophies and goals because the world outside, that brings out misery and homelessness, is organized.

If you look at the term revolution, its evolution the second time. Re-evolution. The first time was an evolution, and the second time is revolution. What we are doing is going back to the old school. We already have the backbone, but now we are in a movement that starts from the heart. Nobody started street medicine.”

Dr. Vargas Vidot, whom those that he has won the hearts of affectionately call Chaco (so everyone he has ever met), started working with HIV/AIDS patients in 1990 to educate them on their condition and possible treatments. From this, Iniciativa Communitaria grew to fight AIDS prejudice, help with prevention and health education, and provide rehabilitation to those in need. Chaco was invited to the International Street Medicine Symposium as the Withers Family Keynote Speaker.

Mander: “I believe in the idea that love can be resistance. Love can be a more radical instrument for changing the world than a weapon in a person’s hand. That is a wonderful idea that attracts me greatly. Listening to the presentations yesterday, it struck me that, quite independently, we have found unconditional love with the homeless. It is relatable to a parent’s relationship to a child. Whether you are good or bad, your parents are going to take care of you, they are going to believe in you, and they aren’t going to toss you out.

And when if you think if something as good or bad, think of it as whether or not it would be good for your own child and then whether or not it would be good for the person in consideration. But with adults I felt like the unconditionality was different. Not unconditional love but unconditional respect. No matter what choices you have made, you are still a human and I could have fallen into the same situation or been born into a different reality. That’s what makes this special. That’s why I come back.

The idea of social protection is the thought that we should take care of each other, but we live in a time where that is considered an extremely subversive and dangerous idea that needs to be crushed at all costs. We are reclaiming that idea that human beings need to take care of each other. When i was young this would be considered humanistic, but we are living in times where this has become revolutionary.”

Harsh Mander has completed extensive work in India and is currently the director of Aman Biradari, an organization dedicated to bringing peace, social equality, and communal harmony to India. With programs like the Dil Se Campaign, which means from the heart in Hindi, to provide food, protection, health care, and education to vulnerable street children, Aman Biradari has a great impact on the lives of many. Mander has also taught classes on poverty to universities at many places, including the Indian Institute of Management, Ahmedabad and the University of California, Los Angeles.

Dr. Prystowsky: “And as a testament to street medicine, what do an untouchable child in Delhi, a prostitute in puerto rico and an alcoholic, drug addict in Pittsburgh have in common? That society has totally counted them out as being a human being, yet there are people who don’t acknowledge that and give them the respect of humans.”

Dr. Vargas: “That’s why I bring up the poem the nobodies. One of the three categories of misery is social exclusion. The system wants to work towards exclusion of the people from this world. It’s what is called learned hopelessness.”

Dr. Prystowsky: “So for the students, learned hopelessness is a fascinating concept. Say you take a rat, and put the rat in a cage, and when that rat goes to one corner of the cage you give it an electric shock. The rat then learns not to go to that part of the cage. If you start randomly giving the rat electric shots no matter what it does, it will curl up in a ball in the center of the cage, and slowly die. That is learned hopelessness.”

Dr. Vargas: “It means social impotence, and it is important to intervene if a person thinks they already lost the battle. They are thinking, ‘Why should I use the last energy I have fighting for something hopeless.’

A person was talking to me in one of the barrios of San Juan, just two weeks ago. She is the leader of the community. I asked her if violence was taking its toll. She said, ‘No because violence only happens at 2am but in the morning is free.

We are in a war. The world is in a state of war and medical doctors around, in the traditional form of medicine, haven’t noticed that.”

Dr. Prystowsky: “What is the role of us, as clinicians, in this war of ideas?”

Dr. Withers: “We have a sacred trust that is a little bit random. Healthcare professionals, doctors in particular, are no better than anybody else, but we have been given this trust. A prostitute will look at you and expect that you care, and a rich banker will do the same thing. It is the unspoken part of a marriage contract and you have to be true to that trust. I think it gives us an awesome responsibility and an amazing potential to relieve suffering, as well as set an example through the health paradigm on how we should treat each other as human beings.

There is a spiritual struggle going on. I’m not sure why the forces of fear and exclusion and hate are building the way that Harsh is suggesting, but I know it’s true and I think we are a direct challenge to that. If we can create a culture that is a different example, the people that are bitter and wounded can see that there is an alternate way. I think there is a lot of potential when you can go through healthcare as relieving suffering, it transcends. I saw this in Nigeria, when I went from the south to the north. Whether it was the Christians or Muslims, there was a shared response to what we were doing that was profound. Everyone attached their own values to what it means to be human.”

Dr. Prystowsky: “In using the language of war, as a society in this war of institutionalized injustice and social classism, how can we as clinicians, who are leaders in our community and have this amazing window as a way to be a role model for social conduct, maintain our effectiveness without losing the integrity and idealism of the movement?”

Mander: “There can be literal ideas of war, of the kind that Chaco is describing, but there is a more fundamental reality of the state being at war with its most vulnerable citizens. It’s not simply just forgetting about them, but it’s actually hostile. The most vulnerable are the people who we feel strangely threatened by. The opposite of love is not hate, but indifference. Our world is characterized by a widespread hate by pervasive indifference and we have to challenge that indifference.”

Dr. Vargas: “They don’t teach that in medical school.”

Dr. Withers: “You will go forward into medical careers and you will go right into it. You will hit it. You will feel it. It will shock you and then slowly, if you aren’t careful, it will numb you.”

Dr. Prystowsky: “How can you immunize students from this?”

Dr. Withers: “A vaccine is reality. Young people respect the truth. They see through semantics, but give in to it after a while. If you give someone a dose of reality, not sugar coated, but a chance to dig their teeth into the real.”

Mander: “Many professions try and teach people not to get involved, but to remain detached. That is something we have to keep fighting. Remain constantly involved, yet don’t become paralyzed so retain the ability to act.
The other thing is that young people are exposed to cynicism. This is the opium of the activist. If nothing is possible then why do I care? I might as well make my money. You have to keep saying however hard the challenge, it is still possible.”

Dr. Prystowsky: “Let me ask you this then. When we talk about the danger of cynicism and apathy, pushing us further from the patient, how do we engage yet still maintain healthy boundaries?”

Mander: “I don’t think the boundaries are as important as the engagement. Working with the homeless children, we tell them ‘Do what you like, I refuse to lose faith in you.’ And they try really hard not to let you down. It’s amazing! They call you Papa, yet sometimes you find someone has embraced you and stolen your mobile phone. Should I check my pockets every time? Or should I say ‘Let’s try again?’”

Dr. Withers: “When I first started going to India, I saw that there was an effect of suffering on the non-sufferers that was profound. I have a degree of empathy for those who had lost their empathy. People were dehumanized because they were guarding their hearts and explaining away other peoples suffering.

The most extreme example I can think of was when women would come in burned, wouldn’t say a word, would stare at the ceiling, and then they would die, even though the burns weren’t bad. I asked my attending what was going on and he said the stoves are very dangerous. The women’s saris would catch fire while they were cooking. So for about a week, I made it my life’s goal to create a stove that was safe. That was going to be my calling.

The truth of the matter was that the women weren’t burned by the stoves. They had kerosene thrown on them and lit on fire by the husband’s family. There was such a conspiracy to push it under the carpet.  It’s an extreme example, but there is toll that the suffering of fellow humans has on everyone. You can demand that we don’t become callous, but have an understanding that there is a process for which it happens. Have some empathy and create a path that isn’t going to frighten people as they come out of their closet of hatred and fear. Remind them that the light won’t hurt them. It’s this spirit that says, “even through all this we can still be human.””

Dr. Prystowsky: “Being in the depths of the work, a lot of the time the team feels the strain of these, as they say in Haiti, ‘mountains beyond mountains.’ How do you keep spirits up and get people to charge forward with the same passion they started with?”

Dr. Vargas: “I am quite familiar with the frontier. We use a strategy which is called ‘The Centrality of Impact.’ If you have 10 cents to solve a problem that requires 1 million dollars to fix, where do you put the ten cents?”

Dr. Prystowsky: “The question for all three of you then is, where do you put your 10 cents today?”

Mander: “There is Buddhist proverb that conveys, rather than running by leaps and bounds in the wrong direction, it is better to be facing the right direction. So I think that partly this movement is about turning in the right direction.

We need to change policy and make bigger things happen, while at the same time keeping our movements afloat. Part of it is reclaiming the idea of a good state and society, redefining it once again in terms of caring.”

Dr. Withers: “I think it goes into the building of the values and solidarity that we desperately need because it takes a toll if we feel alone. At least a couple of cents need to go into reflection on what we are doing. We have all this energy, but we need to link and coordinate to make correct strategic moves.”

Dr. Vargas: “We must feel that the love is more than a word, but an action. Love to me is fighting for the success of my fellow human. My 10 cents should be invested in him, and his in me. Jim is my hero because he has gathered all the 10 cents.”

Dr. Prystowsky: “What advice can you give to students?”

Dr. Vargas: “First you must identify the concrete thing that is really harming the career. It’s not just a talk about idealism but also reality. In medical school you don’t learn medicine just how to pass an exam.”

Dr. Prystowsky: “Are you saying that your skills in doing a standardized exam are not valuable in taking care of people?? There you have it folks!”

Dr. Vargas: “Absolutely. There is an ethical decision a student must make in learning to be a good doctor or learning to pass a test.”

Dr. Withers: “We do something that is very visible and unusual, and that makes it symbolic. But even when I was in the wards, when I was a chief resident, we would go into a patient’s room and, not to be rude, but it was like we were molesting them. We walked in, in our white coats, and interrogate the patient in a directed. We got the “facts”. Then we would go into another room and discuss what it could be, and if you could think through something with more literal searches than someone else you won the game. I realized they didn’t get the history of the patient, they didn’t get the facts. You find that the diagnosis was different, but nobody cared.”

Mander: “You need to tell a young person they are here not because they are the best and passed the exam, but because they are privileged. If people had the same life chances as us their lives would be different. You are not to be blamed for your privilege, but responsible for it.”

Dr. Prystowsky: “How are you able to maintain a consistency with these ideas, while also being able to afford a roof over your own head, and have a family that doesn’t think you are a lousy person because you spend most of your time with prostitutes, untouchable children, and homeless people?”

Dr. Withers: “When my kids were little, I was worried that when they would talk at school they would ask, ‘What does your daddy do?’

‘He’s a fireman.’

‘What does your daddy do?’

‘He’s a policeman.’

‘What does your daddy do?’

‘Well he goes out to the streets at night to give drugs to people, and he has a beeper, and he makes people happy, and now he has a bunch of women that walk the street and work for him.’”

Mander: “This whole business about balance is a very difficult one. The son of Mahatma Gandhi felt that his father had time for goodness, for the world, but never for him. A friend of Gandhi’s offered a scholarship to his son, but Gandhi responded saying, ‘No, everyone is my son, so give it to anybody.’ This was very frustrating for his son, who in the end took his own life. That challenge to find balance between compassion for everyone, and time for your family is tough.”

Dr. Prystowsky: “We are running out of time here, any last pieces of advice?”

Dr. Withers: “Keep your spirit of hope and fun.”

Mander: “Follow your heart without consideration of the consequences.”

Dr. Vargas: “Look for the fun. This is not a sad thing, it’s an adventure of life. Always think about the person as a whole. I have a medical student in Haiti who, when I asked him if I should put confidence in Francois, he replied, ‘Dr. Chaco, every single human being has a dark side and a light side. In which side are you going to put your confidence?’ Put your faith in the light side.”

. . .

As I left Starbucks that morning, my mind was on tilt. How could something such as street medicine, something that felt so natural and was founded in love for fellow human beings, face so many obstacles? This tilt, however, was not based in negativity, but optimism. People like Dr. Withers, Dr. Vargas, and Mr. Mander were creating change, and it was up to the next generation to facilitate the continuation of that movement. All the rest of my time in Boston, I felt the momentum. People from all around the world coming together, sharing ideas, helping one another overcome obstacles so that we all could take back what we learned and provide a better service to our beneficiaries. The plane ride back was miserable. Thirty thousand feet in the air, with the “fasten seatbelt” sign staring me down, holding me back, when all I wanted to do was get up and make something happen, make some sort of difference. Luckily, there are these fancy little machines called laptops these days, and I whipped mine out and started typing away. For that six hour flight home, change was quite literally in the air.

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