Street Medicine – A Brief Overview

Dr. James Withers
Founder, International Street Medicine Institute and the Operation Safety Net
2011

In 1992, I dressed as a homeless person and made medical visits to the streets of Pittsburgh with a formerly homeless man. My goal as a teaching physician was to find a “classroom” that would allow the students to work in the reality of the alienated and excluded part of our city.

When street medicine started, there was no template for delivery of care except for some wilderness medicine training and trips.  We listened and tried to understand the circumstances of the street homeless – eventually working in partnerships to address the loose ends of their health care.  My backpack got bigger and others joined the work. We created Operation Safety Net with the mission to ensure that nobody falls through the cracks to simply die on the streets.

One of the fortunate aspects of the endeavor was that we had formerly homeless partners leading the way from the beginning.  My longtime friend Mike Sallows was the initial guide to the streets, and he continues to work with me every week on our rounds.  We continue to have formerly homeless persons on each outreach team, which usually includes a nurse, physician, medical student and social worker, searching for the hidden homeless. To provide more in-depth interaction, there is a large mobile home where patients can be examined in private.  All street medicine programs build from the streets up, so everything is grounded in the reality of the unsheltered homeless.

       At the core, I sought to base our work on the streets (“street medicine”) on a deep philosophical basis that would meet people in their own reality.  Much of health care is based on making people come to where the medicine is and forcing them to fit into boxes designed for the comfort of practitioners.  This excludes those who cannot come to systems, but need doctors and nurses where they are. The current system distorts healing for those needing it most.

Street work is a chance for a fresh start; to challenge medical colleagues to join in the effort “out there” where real people are in need.  Many respond positively, while others feel threatened, but the exploration of reality is an essential part of the dialogue.  Such open dialogue will succeed in shaping the nature of health care.

Currently, Operation Safety Net’s staff of 21 offers a wide array of social services that specifically target the street homeless population.  Support comes from a variety of sources including private donations, grants and volunteer efforts.  Medical coverage is 24/7, and a toll free number is available for any homeless person, Emergency Room staff member or other concerned people.  Within 24 hours, in-person follow up occurs on the needs identified.  This allows construction of treatment plans for each individual person.  A hospital consult service serves as an example of how to use every opportunity to work towards the goal of better health immediately.  Street Medicine programs save hundreds of thousands of dollars in health care and other costs for their larger communities each year.  Since 2007, over 700 chronically homeless individuals in Philadelphia have moved into their own apartments. Over 100 students work with us each year from a wide array of disciplines. A naturally multi-disciplinary model is more of a community approach than a specialized focus.

Street medicine is far more than a delivery model for health care.  One of the most critical elements of street medicine programs is that they create a framework upon other efforts and can be built outward to serve the street homeless.  For example, through ongoing trusting relationships with the street homeless, Philly now has nine  law firms that assist homeless people with their legal issues.  Virtually any organization, such as our local domestic violence agency or our psychiatric systems, can connect with the most vulnerable who were previously “out of reach.”  I have seen this play out strongly in Doctors Without Walls – Santa Barbara Street Medicine, and other street medicine programs throughout the U.S. and abroad.  The woven fabric of community is literally  extended to link us all together.

       Because street medicine programs “go to the people,” they are incredibly strategic as an interface between the street homeless and the larger community.  As such, we have an opportunity and moral obligation to humanize our communities.  Each encounter with our friends on the street is a chance to show that there are those who care deeply about them.  We try to listen and fully engage the reality that they experience.  Often just being able to express their story fully is a tremendous benefit for those who have been dismissed by society.  Healing begins with listening.  And as we have dialogue with those in the larger community, we can address the prejudices and frustrations they hold.   Ideally, the frank exploration of reality – without judgment or condition – can create the groundwork for healing at the community level.  But for each person on the street, it means listening to the specifics of their situation and discovering how to partner with them in such a way that we share the reality they experience daily.

I am delighted and inspired to have witnessed the birth and growth of Doctors Without Walls (DWW).  In a way it is like seeing the miracle of Operation Safety Net happen all over again, but with different challenges and victories.  I had the advantage of a large mission-based parent organization to which I could relate – though we had to largely fend for ourselves in terms of funding and community relationships.  For all of you in Santa Barbara, it has been much more of a “wilderness experience.”  Where other programs might depend on an existing structure, DWW relies of the willingness of volunteers to share in the responsibility to meet the needs of those you serve.  I am convinced it has made you a better organization despite the challenge.  Mimi, Jennifer, Father Jon, and now so many others like Jason, Laura, Marguerite and the student leaders have become heroes to me by your example of dedicated volunteer service.  It is my sincere hope that you will receive the support in your community to allow you to do even more.

Street medicine has become a global movement.  Since I first connected with Dr. Jack Preger in Calcutta in 1993, a network of over 80 communities practicing street medicine has emerged.  It is essential that we support each other.  For most of those practicing street medicine, we are largely “homeless” ourselves in our own communities.  Not only is the practice not recognized, but the values we hold that prioritize the value of the most vulnerable are also not embraced by mainstream health care.  As I traveled to communities throughout the U.S. and other countries, I sensed a burning desire amongst street medicine practitioners to link together for insight and encouragement.  To bring them together, we created the annual International Street Medicine Symposium in 2005.  The first was held in Pittsburgh, the second was in Santa Barbara.   To date, we have held seven highly successful symposia and are planning the next for October 2012.  These meetings have begun to build the kind of unity that is needed to validate street medicine as an actual field of medicine.  In 2008, we officially launched the Street Medicine Institute.  Both the annual symposium and the Institute were made possible by the generous support of GlaxoSmithKline.  This Street Medicine Institute is now the “home” of street medicine (www.streetmedicine.org) and will serve the following four key purposes:

-       To assist communities seeking to establish their own street medicine programs

-       To define and improve the practice of street medicine

-       To host the annual International Street Medicine Symposium

-       To provide educational opportunities (such as the Street Medicine Fellowship)

The future of street medicine resides in the innate quality of active social justice.  Those working directly with the rejected members of their communities challenge others sitting on the side lines.  Barriers are broken down and reality-based solutions are found.   The beauty is in solving problems together.

The essence of street medicine is the Golden Rule – doing as we would have others do if we were in their shoes.  This requires us to believe others are worthy enough to deserve our compassion … and we are ultimately connected as brothers and sisters.

The Street Medicine Institute is incredibly proud of these accomplishments.  We remain committed to working in solidarity with others to fulfill the vision of street medicine as a source of true healing.