Health and Homelessness: On the front lines w/Dr. Jim O’Connell

By Amanda Waldroupe, Staff Writer

Dr. Jim O’Connell had dreams of becoming a country doctor when he graduated from Harvard Medical school in 1982. Taken by the way medicine was studied and practiced in a large academic center, he chose instead to work toward becoming an oncologist and started his internship at Massachusetts General Hospital.

In 1985, his chief of medicine called him into his office and told O’Connell that the Robert Wood Johnson Foundation had given the city of Boston funding to start an organization devoted to providing primary health care to homeless people. O’Connell was asked if he would mind being the program’s only full-time doctor for one year, as a way of involving Massachusetts General in the program. “(A) kind of urban Peace Corps,” O’Connell thought.

One year turned into 25. O’Connell, now 62, became the founding physician of the Boston Health Care for the Homeless Program, which has become the country’s largest and most comprehensive program providing health care to the homeless.

The program serves 11,000 each year.  Services are provided at two hospital-based clinics, over 80 Boston shelters and agencies, and a 104-bed medical facility providing acute, sub-acute, post-operative, recuperative, rehabilitative and end-of-life care.

O’Connell’s research on the relationship between homelessness and increased health problems and likelihood of death has been widely published. One study was noticed by the New York nonprofit Common Ground, which subsequently created the Vulnerability Index survey (see “Measuring our Vulnerability,” Street Roots, Oct. 31, 2008).

Starting in 1986, O’Connell began providing medical care two nights a week out of an outreach van operated by a Boston outreach agency. The experience of being a street physician has taught him that homeless people can receive the same level of medical care on the streets as in a clinic, and that the most important key to providing quality and continuity of care are the relationships that are forged.

Amanda Waldroupe: What do you enjoy about being a street physician?

Jim O’Connell: I certainly enjoy the complexity of illness and trying to figure out how to diagnose, care for and finding treatment plans for people that are practical. I love working in teams. What keeps everyone going, virtually, is getting to know the stories of people over time. (They) are more often than not tales of breathtaking courage. Those stories really grab you, and its very hard for you to not to become enraptured and engaged.

A.W.: It’s pretty obvious that homeless people will become more unhealthy while they are homeless. Do you think people realize that?

J.O.: No. I think it’s hard for people to see.

A.W.: How can increased awareness about homeless people’s health affect government’s efforts to end homelessness?

J.O.: I think that we need to do everything we can to raise awareness of what I would call the public health emergency of people living on the streets. Their mortality rates are so high. The outcomes from their illnesses are so appalling. If this were any other population, we would have major programs to address health disparities.

A.W.: Do you think Boston Healthcare for the Homeless has helped change the way Bostonians view homelessness?

J.O.: Especially for the politicians and the lay people, I think our presence has been able to put some order into what seemed chaotic. It’s not as if anyone is not caring for them. What we’ve been able to do is put a human face on the tragedy. Rather than it being a person causing a problem with McDonald’s, if we can put face on it with someone struggling with cancer who really just needs help, we have options other than jail. I don’t want to pretend Boston has turned into a completely loving city, but it’s a pretty damn humane approach.

A.W.: You think that the same amount of homeless people die in the summer time as in the winter time. Why is that?

J.O.: I have lots of theories. The most dangerous months are September, October, and November. We think a lot of people stay out during the summer time. They don’t take care of themselves. But the end of the summer, they’re emaciated and very, very vulnerable.

A.W.: Because they stay in shelters during the winter?

J.O.: They’re not as hard core at surviving as some of the year-rounders.

A.W.: Does Boston somehow keep track of how many homeless die each year?

J.O.: We do keep track of the number of people who die. But the trouble is that it is very hard to get a denominator.  We know it’s about 200 on average. It’s tough, because you don’t know whether they’re dying in hospitals, or in jails. Finding the number in an accurate way is challenging.

A.W.: Do you think that information is important to track?

J.O.: The tragedy of dying alone on the streets, separated from family and friends, has always been something that is hard for any one citizen to turn your heart away from. It has been a very important way to keep people aware of how deadly homelessness can be.

A.W.: How is the population of “year-rounders” different from other populations of homeless people?

J.O.: One, they die at greater rates. They use emergency rooms at extraordinary rates. They are the ones that get the most problems from exposure to the elements, both heat and cold. They are also the ones that are most consistently exposed to violence and trauma. They are a very vulnerable group. The incidents of serious and high medical problems is high in this group.

A.W.: What are the most common diseases and illnesses you see?

J.O.: We see all sorts of things. Diabetes. High blood pressure. HIV. COPD [Chronic Obstructive Pulmonary Disease]. AIDS. Asthma. Emphysema. This is one of our most vulnerable subgroups that we know of in America. Their mortality is high. They have astonishing health disparities. They have more cancer. The second most common disease is end-stage liver disease. We get deaths from AIDS. These are things we should either be preventing or managing better. If you start to care for our homeless … they will show us the weaknesses in our mainstream system, particularly with healthcare.

A.W.: You still go out two nights every week.

J.O.: I still ride the van every Monday and Wednesday night from nine at night to five in the morning. I cheat a lot (laughs). I feel like I’m an intern those days. Those are the long days. It’s unbelievably fun and important. I can actually see what’s going on the streets and where people are coming from.

A.W.: You said your outreach team combines medical and mental health care. Why is that important?

J.O.: We are dealing with a population that has co-occurring medical illnesses, substance abuse and mental illnesses. Treatment and the care of those people needs to be fully integrated where you have medically care fully integrated with mental and substance abuse care. I can just see them together with our psychiatrist and deal with the whole person rather than separate it out. It was something I never got to do other than training at the hospital. If we send a team that is fully integrated, we can do a lot.

A.W.: Why is it important that the van be an outreach van and not specifically a medical outreach van?

J.O.: We decided at that time to make it a van that would bring things to people (such as soup, sandwiches, and blankets), and that it would be a consistent life line for people. It turned out to be a pretty brilliant move. The drivers and the staff … develop huge, powerful relationships. We can piggy back on all that good will. It’s a back-door way to health care. It requires that the doctors and the health care providers recognize their role as behind the scenes and emerge only slowly.

A.W.: You can reach people in a different way.

J.O.: What we end up doing is visiting people in their homes. At first, that was invasive to people. Our street clinic at Mass General, which I once would have bet you would never have made it, is the biggest and most consistent clinic in our program. They know the staff. Even if it’s a fancy hospital, they come to our waiting room. Most people hear about the clinic from their friends, and they’ll come. I think you can remove the stigma.

A.W.: What are some of the challenges to getting people living on the streets to follow a treatment plan?

J.O.: We almost always get to know people and what they’re capable of. What we’ve learned is that everyone is an individual. We used to be afraid to give people HIV meds in the chaos of the streets. But certain people on the street are extremely meticulous about taking their medication. There are others that have lives too chaotic. We find them each day to help them take their medication.

A.W.: So there’s never a time when you can’t provide treatment to someone for one thing or another.

J.O.: We never give up. But sometimes treatment is something they’re not ready to consider, and it’s really hard then. But we try to work on things. There are tough situations. I think another thing that happens on the street a lot is that they have lost all hope — not actively committing suicide, but completely given up. A lot of what we do is try to restore hope.

Photo by Rick Freeman