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Medical Program: Protecting the Vulnerable from COVID-19: A Street Physician’s Perspective

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  • Overview

    The street medicine movement is faced with the challenge of administering treatments and protection methods to a population that is often excluded and in dire need of care, and that challenge has only been intensified during this unprecedented time. Street physician Dr. Jim Withers, who’s credited with starting the street medicine movement, is here to share what it’s like to care for the homeless during the COVID-19 pandemic.

    Published April 27, 2020

  • Read the Article

    Protecting the Vulnerable from COVID-19: A Street Physician’s Perspective

    Dr. Johnson:
    Today, COVID-19 has approximately 95% of America’s population, or 306 million people in the United States, on some form of lockdown. The majority of the population is listening and taking some form of social distancing seriously in an attempt to control the pandemic, but what happens when your home is made up of cardboard boxes under an overpass or you’ve been sleeping in the doorway of a closed business? What happens if you’re homeless and you only have an 8th grade education or that it’s compounded with a mental illness? 

    Welcome to COVID-19: On the Frontlines with ReachMD. I’m Dr. Shira Johnson.

    Today, I’m fortunate to have with me Dr. Jim Withers, known as the people’s street physician. Jim was the man who brought healthcare to the homeless and started the street medicine movement. He began in the late 1980s working solo in Pittsburgh and by 1992, he started garnishing support from the Sisters of Mercy and his academic institution. His work expanded, and he later established Pittsburgh’s Mercy Operation Safety Net. Today, they offer outreach case management and links to integrated healthcare and housing, having touched over 10,000 lives, but Jim and his colleagues wanted to do more, and in 2009, they founded the Street Medicine Institute. They took this movement to over 80 cities within 51 countries, and we are honored to have him with us today. Thank you so much for joining us Jim.

    Dr. Withers:
    My honor.

    Dr. Johnson:
    Jim, before I ask you about the state of street medicine today, can you take a few minutes and tell our listeners how you got started in street medicine?

    Dr. Withers:
    Well, the platform from which I launched my street career was as a teaching physician in an intercity hospital, the Mercy Hospital, which had a tradition of taking care of the excluded, poor, and vulnerable population of central Pittsburgh, and exploring that terrain academically, educationally, as well as taking care of people, I realized that there was a gap between the reality of the hospital system and how we conducted our healthcare and the actual experiences of people. My initial interest in a population started with domestic violence, and the further I got involved in domestic violence work, looking at the dynamics of it, the barriers to care, but also the attitudes towards this population within the health system. I began to look at the hospital and the health system and medical education as the patient because we have this inability to crossover into the reality of excluded people. And so, to really push that educationally, I decided I needed a new classroom, and I decided the classroom of the streets would be a really conveniently located, compelling, and transformative environment for practicing and learning about the care. It goes back to my childhood when I made house calls with my dad in rural Pennsylvania and in essence, I think I was just reinventing the notion of house calls, but I wanted to go into the homeless camps and under the bridges as a way of forcing myself to begin with the reality of people, as opposed to making them adapt to the constraints of a complicated system.

    Dr. Johnson:
    And that really established the idea for street medicine today, can you tell us Jim, some of the early challenges that you faced, and how did you overcome them?

    Dr. Withers:
    Well, it was really like being in another country. The people on the street embraced me pretty quickly due to the fact that I had a formerly homeless partner that knew them, and so I was very humbled by their willingness to accept me as their doctor. And yet it didn’t take me long to see how hostile the system looked from the street level. Many of the people would rather die than engage healthcare because of how they’ve been treated or how frustrating it was. I really didn’t have a template, and it wasn’t until I traveled to India and met Dr. Praeger in the streets of Calcutta that I found another person doing what we now call street medicine, and it just seemed like it was such a essential function on so many levels, almost like having a fire department in a city, as far as the wellbeing of people living outdoors.

    Dr. Johnson:
    When did you and your team in Pittsburgh become aware of COVID-19, and what were your early thoughts on this pandemic?

    Dr. Withers:
    I think many of us were already in the mode of thinking about what would happen to our people if something happened like this. We’ve dealt with weather. We’ve dealt with all kinds of other issues with the population. So, we were more attuned to this, and ready for it than the other members of our healthcare system here. But, I don’t think it was until February that it really looked like this was going to be the kind of a problem that it was. As we followed it from China and throughout the globe on the news, we knew that when it came the homeless themselves would be at very high risk for mortality and morbidity and just exclusion again. They always seem to be the people that are neglected whenever there’s health needs. So, we were prepared and pretty much ready for action by the beginning of March. The thing that I love to talk about is how we had to kind of re-tool all of our practice. We don’t do primary care, but we try to bring as close to primary care as we can to the streets and yet this really shifted us into an epidemiological mode of thinking. So, we had to re-tool all of our protocols and policies and procedures on the street in very short order here in Pittsburgh. It was not long after that I realized that the street medicine community, at least in the United States, would need a guidebook. And, so by the second week of March, the Street Medicine Institute leadership was able to produce practice guidelines for the pandemic. And that’s available on the streetmedicine.org website to all the partners that do this kind of work.

    Dr. Johnson:
    For those of you just tuning in, this is COVID-19 On the Frontlines on ReachMD. I’m Dr. Shira Johnson and today I’m speaking with Dr. Jim Withers, who is sharing his experiences in street medicine and how his pioneer organization, Pittsburgh’s Mercy Operation Safety Net, is responding to the COVID-19 outbreak.
    So, Jim, tell us some more about what your team is doing now in response to COVID-19 and its grip on the homeless?

    Dr. Withers:
    We don’t have as many people in the field just due to CDC guidelines. Most teams that I am aware of just have a few highly trained medical professionals in the field going to the camps and working with them in terms of public health education, developing communication strategies with the homeless population. Because we have their trust, we’re able to engage their leadership. We’ve been able to get more cell phones out there so that people can text if they see others that are in need or if they’re having a crisis. And then when we have individuals that may have COVID, then we have protocols for doing testing right out in the campsites and under the bridges. There’s a lot of work being done behind the scenes. We try to make sure people are getting food and water because in Pittsburgh and other places, it looks like people are really desperate for the basic resources that have become more difficult to access.

    Dr. Johnson:
    Right because resources they had are being cut off. The pantries, water supply, the teams that are going out to the streets they can't be there right now because of the large homeless population, is that correct?

    Dr. Withers:
    That’s right. And a lot of well intentioned changes have been made to decrease aggregate, congregate, sort of settings, but, the people on the streets really rely on those things for basic survival, and so, we partner with others to make effective-like packages of food that we can do drop-offs on. One of the things that we did, I think, that was really good, was with the city, we were able to put in outdoor sinks, outdoor water supplies, and toilets at the major campsites so that people can wash their hands, and it’s really changed the way we’re looking at the work to put it in this epidemic mindset.

    Dr. Johnson:
    Are people responsive to assisting your teams going out and are you physically able to be effective in getting water supply to tent cities and other places where they’re camping out, its all been evolving so very rapidly.

    Dr. Withers:
    The larger campsites, I think, really appreciate it. There’s an emotional closeness that we’ve developed with their leadership and a sense of solidarity that is even more profound than that which we have developed over the years of working on the street. They look out for each other. That’s always been the case, but I see an awful lot of natural leadership emerging from the streets to help us work with them and to identify people that might be at risk.

    Dr. Johnson:
    I know your organization The Street Medicine Institute helps many smaller organizations all across the country giving advice, support and the sharing of ideas and protocols for the best practices in delivering street medicine. Can you comment on the impact of COVID-19 on the smaller non-profits all across the country? I would imagine that they would like most of us did not see it coming and now they want to be out on the streets and some providers will go with them to deliver an essential service regardless of stay at home orders. Can you comment on this challenge? 

    Dr. Withers:
    Small areas and cities have their own ways of either embracing this as a community or pushing aside the people that are on their streets and even closing down some of the resources that they need. I spoke to Crystal Bauer in Wheeling, West Virginia, and they’re facing a lot more shortages in terms of personal protective equipment and some of the resources for isolation and quarantine that we are able to do at slightly larger cities. One of the things that she developed with the homeless themselves, which I liked, was they have a flag system where if the people in the camp are all doing well, they put up a green flag, and the team can come and just see that. If someone’s in trouble, they’ll put up a red flag and that way they don’t have to have too much interaction. But resources for people in these settings are really difficult, and people can’t go to the drive-through COVID testing of course. Some of them have to walk seven miles just to get a test. And many of their people are close to starvation really in terms of access to food. So, I think the small communities are dealing with a lack of resources and sometimes just not the unified commitment to the homeless that a larger city would have.

    Dr. Johnson:
    So, Jim, to close, you’ve given us so much information, but what is the message that you would like to get out to all the medical providers that may be listening to us now?

    Dr. Withers:
    I think this is a time when we often are facing a decision. Are we going to go towards the people that are in most need and excluded, or are we going to run away from them? Are we going to retract? So, I think this is an opportunity to look at healthcare in a much more global way seeing that we’re all connected, a public health approach if you will, but also a chance to kind of look at what healthcare really is. It’s not just a business. It’s not just something you can bill people for, but it’s a sacred calling. And we certainly have that sense and I see that in the stories of other healthcare professionals and people that are still serving the public. So, I think it’s a chance for us to deepen our commitment to each other and also in healthcare to what it means to be a physician or healthcare worker and hopefully, we can come out of this having that fabric of a shared community, much stronger and much more broad so that we can not just respond to crises, but we can commit ourselves to the wellbeing of our brothers and sisters throughout our communities.

    Dr. Johnson:
    Jim, I agree. It is a sense of calling. I want to deeply thank you, not just for the interview today, but for all the work and your team have been doing and continuing to do and for giving us your unique prospective as a street medicine doctor during this global pandemic and even before this pandemic. Thank you very much for your service.

    Dr. Withers:
    Thank you. 

    For ReachMD this is COVID-19: On the Frontlines. For continuing access to this and other episodes and to add your perspectives to the fight against this global pandemic visit us at ReachMD.com and become part of the knowledge. Thank you for listening. 

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  • Overview

    The street medicine movement is faced with the challenge of administering treatments and protection methods to a population that is often excluded and in dire need of care, and that challenge has only been intensified during this unprecedented time. Street physician Dr. Jim Withers, who’s credited with starting the street medicine movement, is here to share what it’s like to care for the homeless during the COVID-19 pandemic.

    Published April 27, 2020

  • Read the Article

    Protecting the Vulnerable from COVID-19: A Street Physician’s Perspective

    Dr. Johnson:
    Today, COVID-19 has approximately 95% of America’s population, or 306 million people in the United States, on some form of lockdown. The majority of the population is listening and taking some form of social distancing seriously in an attempt to control the pandemic, but what happens when your home is made up of cardboard boxes under an overpass or you’ve been sleeping in the doorway of a closed business? What happens if you’re homeless and you only have an 8th grade education or that it’s compounded with a mental illness? 

    Welcome to COVID-19: On the Frontlines with ReachMD. I’m Dr. Shira Johnson.

    Today, I’m fortunate to have with me Dr. Jim Withers, known as the people’s street physician. Jim was the man who brought healthcare to the homeless and started the street medicine movement. He began in the late 1980s working solo in Pittsburgh and by 1992, he started garnishing support from the Sisters of Mercy and his academic institution. His work expanded, and he later established Pittsburgh’s Mercy Operation Safety Net. Today, they offer outreach case management and links to integrated healthcare and housing, having touched over 10,000 lives, but Jim and his colleagues wanted to do more, and in 2009, they founded the Street Medicine Institute. They took this movement to over 80 cities within 51 countries, and we are honored to have him with us today. Thank you so much for joining us Jim.

    Dr. Withers:
    My honor.

    Dr. Johnson:
    Jim, before I ask you about the state of street medicine today, can you take a few minutes and tell our listeners how you got started in street medicine?

    Dr. Withers:
    Well, the platform from which I launched my street career was as a teaching physician in an intercity hospital, the Mercy Hospital, which had a tradition of taking care of the excluded, poor, and vulnerable population of central Pittsburgh, and exploring that terrain academically, educationally, as well as taking care of people, I realized that there was a gap between the reality of the hospital system and how we conducted our healthcare and the actual experiences of people. My initial interest in a population started with domestic violence, and the further I got involved in domestic violence work, looking at the dynamics of it, the barriers to care, but also the attitudes towards this population within the health system. I began to look at the hospital and the health system and medical education as the patient because we have this inability to crossover into the reality of excluded people. And so, to really push that educationally, I decided I needed a new classroom, and I decided the classroom of the streets would be a really conveniently located, compelling, and transformative environment for practicing and learning about the care. It goes back to my childhood when I made house calls with my dad in rural Pennsylvania and in essence, I think I was just reinventing the notion of house calls, but I wanted to go into the homeless camps and under the bridges as a way of forcing myself to begin with the reality of people, as opposed to making them adapt to the constraints of a complicated system.

    Dr. Johnson:
    And that really established the idea for street medicine today, can you tell us Jim, some of the early challenges that you faced, and how did you overcome them?

    Dr. Withers:
    Well, it was really like being in another country. The people on the street embraced me pretty quickly due to the fact that I had a formerly homeless partner that knew them, and so I was very humbled by their willingness to accept me as their doctor. And yet it didn’t take me long to see how hostile the system looked from the street level. Many of the people would rather die than engage healthcare because of how they’ve been treated or how frustrating it was. I really didn’t have a template, and it wasn’t until I traveled to India and met Dr. Praeger in the streets of Calcutta that I found another person doing what we now call street medicine, and it just seemed like it was such a essential function on so many levels, almost like having a fire department in a city, as far as the wellbeing of people living outdoors.

    Dr. Johnson:
    When did you and your team in Pittsburgh become aware of COVID-19, and what were your early thoughts on this pandemic?

    Dr. Withers:
    I think many of us were already in the mode of thinking about what would happen to our people if something happened like this. We’ve dealt with weather. We’ve dealt with all kinds of other issues with the population. So, we were more attuned to this, and ready for it than the other members of our healthcare system here. But, I don’t think it was until February that it really looked like this was going to be the kind of a problem that it was. As we followed it from China and throughout the globe on the news, we knew that when it came the homeless themselves would be at very high risk for mortality and morbidity and just exclusion again. They always seem to be the people that are neglected whenever there’s health needs. So, we were prepared and pretty much ready for action by the beginning of March. The thing that I love to talk about is how we had to kind of re-tool all of our practice. We don’t do primary care, but we try to bring as close to primary care as we can to the streets and yet this really shifted us into an epidemiological mode of thinking. So, we had to re-tool all of our protocols and policies and procedures on the street in very short order here in Pittsburgh. It was not long after that I realized that the street medicine community, at least in the United States, would need a guidebook. And, so by the second week of March, the Street Medicine Institute leadership was able to produce practice guidelines for the pandemic. And that’s available on the streetmedicine.org website to all the partners that do this kind of work.

    Dr. Johnson:
    For those of you just tuning in, this is COVID-19 On the Frontlines on ReachMD. I’m Dr. Shira Johnson and today I’m speaking with Dr. Jim Withers, who is sharing his experiences in street medicine and how his pioneer organization, Pittsburgh’s Mercy Operation Safety Net, is responding to the COVID-19 outbreak.
    So, Jim, tell us some more about what your team is doing now in response to COVID-19 and its grip on the homeless?

    Dr. Withers:
    We don’t have as many people in the field just due to CDC guidelines. Most teams that I am aware of just have a few highly trained medical professionals in the field going to the camps and working with them in terms of public health education, developing communication strategies with the homeless population. Because we have their trust, we’re able to engage their leadership. We’ve been able to get more cell phones out there so that people can text if they see others that are in need or if they’re having a crisis. And then when we have individuals that may have COVID, then we have protocols for doing testing right out in the campsites and under the bridges. There’s a lot of work being done behind the scenes. We try to make sure people are getting food and water because in Pittsburgh and other places, it looks like people are really desperate for the basic resources that have become more difficult to access.

    Dr. Johnson:
    Right because resources they had are being cut off. The pantries, water supply, the teams that are going out to the streets they can't be there right now because of the large homeless population, is that correct?

    Dr. Withers:
    That’s right. And a lot of well intentioned changes have been made to decrease aggregate, congregate, sort of settings, but, the people on the streets really rely on those things for basic survival, and so, we partner with others to make effective-like packages of food that we can do drop-offs on. One of the things that we did, I think, that was really good, was with the city, we were able to put in outdoor sinks, outdoor water supplies, and toilets at the major campsites so that people can wash their hands, and it’s really changed the way we’re looking at the work to put it in this epidemic mindset.

    Dr. Johnson:
    Are people responsive to assisting your teams going out and are you physically able to be effective in getting water supply to tent cities and other places where they’re camping out, its all been evolving so very rapidly.

    Dr. Withers:
    The larger campsites, I think, really appreciate it. There’s an emotional closeness that we’ve developed with their leadership and a sense of solidarity that is even more profound than that which we have developed over the years of working on the street. They look out for each other. That’s always been the case, but I see an awful lot of natural leadership emerging from the streets to help us work with them and to identify people that might be at risk.

    Dr. Johnson:
    I know your organization The Street Medicine Institute helps many smaller organizations all across the country giving advice, support and the sharing of ideas and protocols for the best practices in delivering street medicine. Can you comment on the impact of COVID-19 on the smaller non-profits all across the country? I would imagine that they would like most of us did not see it coming and now they want to be out on the streets and some providers will go with them to deliver an essential service regardless of stay at home orders. Can you comment on this challenge? 

    Dr. Withers:
    Small areas and cities have their own ways of either embracing this as a community or pushing aside the people that are on their streets and even closing down some of the resources that they need. I spoke to Crystal Bauer in Wheeling, West Virginia, and they’re facing a lot more shortages in terms of personal protective equipment and some of the resources for isolation and quarantine that we are able to do at slightly larger cities. One of the things that she developed with the homeless themselves, which I liked, was they have a flag system where if the people in the camp are all doing well, they put up a green flag, and the team can come and just see that. If someone’s in trouble, they’ll put up a red flag and that way they don’t have to have too much interaction. But resources for people in these settings are really difficult, and people can’t go to the drive-through COVID testing of course. Some of them have to walk seven miles just to get a test. And many of their people are close to starvation really in terms of access to food. So, I think the small communities are dealing with a lack of resources and sometimes just not the unified commitment to the homeless that a larger city would have.

    Dr. Johnson:
    So, Jim, to close, you’ve given us so much information, but what is the message that you would like to get out to all the medical providers that may be listening to us now?

    Dr. Withers:
    I think this is a time when we often are facing a decision. Are we going to go towards the people that are in most need and excluded, or are we going to run away from them? Are we going to retract? So, I think this is an opportunity to look at healthcare in a much more global way seeing that we’re all connected, a public health approach if you will, but also a chance to kind of look at what healthcare really is. It’s not just a business. It’s not just something you can bill people for, but it’s a sacred calling. And we certainly have that sense and I see that in the stories of other healthcare professionals and people that are still serving the public. So, I think it’s a chance for us to deepen our commitment to each other and also in healthcare to what it means to be a physician or healthcare worker and hopefully, we can come out of this having that fabric of a shared community, much stronger and much more broad so that we can not just respond to crises, but we can commit ourselves to the wellbeing of our brothers and sisters throughout our communities.

    Dr. Johnson:
    Jim, I agree. It is a sense of calling. I want to deeply thank you, not just for the interview today, but for all the work and your team have been doing and continuing to do and for giving us your unique prospective as a street medicine doctor during this global pandemic and even before this pandemic. Thank you very much for your service.

    Dr. Withers:
    Thank you. 

    For ReachMD this is COVID-19: On the Frontlines. For continuing access to this and other episodes and to add your perspectives to the fight against this global pandemic visit us at ReachMD.com and become part of the knowledge. Thank you for listening. 

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