As a fourth-year medical student hoping to match into an emergency medicine residency, Healthcare for the Homeless (HCH) seemed like a no-brainer rotation to complete.
I had an interest in the population after attending a talk by Doctor Jim O’Connell when I was working down in Boston. Dr. O’Connell is responsible for shaping Boston Healthcare for the Homeless, which is one the most robust HCH programs in the country (I recommend reading his book Stories from the Shadows if my rambling piques your interest).
It meant even more to me to do the rotation in Manchester, my de facto hometown (growing up in Goffstown, just on the line). I knew that people experiencing homelessness are one of the most marginalized groups, and they are often high utilizers of emergency medicine services; and unfortunately for several of these individuals, the only medical care they receive is when they cross the threshold of an Emergency Department (ED).
Often these patients are non-compliant with their discharge instructions, but it’s hard to blame them with the tumultuous goings-on of their day-to-day life on the streets. Plus, a majority of the people experiencing homelessness are often experiencing some psychiatric, or addiction affliction as well, making it almost impossible to navigate the exceptionally complicated minefield we call modern medicine. They are high utilizers because they often re-present to the ED with the same or worsening complaints, and require a repeat workup for their various maladies.
I could see the burn-out and jaded attitudes occasionally from ED docs and nurses, and frankly, I could understand their exasperation at dealing with many of these difficult patients time and time again. It’s a vicious cycle, the person is unable to follow up, and the ED staff are only able to bridge the patient (just ensure the patient they aren’t actively dying and don’t need to be admitted) with some therapeutics until they can follow up out-patient.
But alas, these patients lack critical access to out-patient care, and instead come back when their symptoms worsen, as they are told to. The vicious part of the cycle comes from patients then being distrustful and hostile after the ED was unable to “fix” their complaint. Although the ED staff are doing their best to treat the patient despite this hostility, even the most altruistic and empathetic of healthcare workers become cold and jaded by this repetitive dance.
Since I plan on being in Emergency Medicine, HCH is the obvious choice for my rotation. I got my ducks in a row and was able to land a four-week rotation to see what an HCH organization could offer and what resources are at the disposal of a HCH clinic. My time was spent mostly at the clinic that is beneath the New Horizons Shelter on Manchester Street. If you ever have driven by the shelter you would know the area well. It’s hard to miss with the mass of people that congregate outside every day, as they are unable to stay inside during the day and only permitted re-entry for meals before being promptly sent back out, until they can move back in for the night.
It doesn’t feel like the most welcoming of environments, especially from a kid that grew up in suburbia, over in Goffstown. I felt pretty uncomfortable walking into the shelter on my first day. If the large groups of people amassing outside the shelter standing among the numerous cigarette butts, food wrappers, and discarded clothing felt unwelcoming, then the waiting room of the clinic wasn’t much of an improvement. The clinic is in the basement of the New Horizons shelter, with high concrete walls, six chairs spread apart by at least six feet, all basked in the iridescent yellow glow of the aged fluorescent lights.
The sheer emptiness of the room felt more like jail than any “clinic” I have ever seen. Later, someone tells me that it was an old bomb shelter. I’m not sure of the validity of that statement, but it definitely feels true. Thankfully the staff is unperturbed by the appearance of the clinic, likely having gotten used to the conditions. It consists of three exam rooms, two nursing triage areas, a check-in off the main lobby, a few offices and a break room that doubles as the storage area, and triples as the meeting room.
Unfortunately, they do not even have enough space for a patient restroom, so they must go up to the shelter restroom accompanied by nursing when needing to give a sample of urine. Despite the clear facility lacking, the staff at Manchester Healthcare for The Homeless does an incredible and absolutely essential job.
For the majority of my four weeks there, I would spend three to four days in the clinic, working with the primary care providers. What the clinic lacks aesthetically it makes up for in care. They are a fully integrated clinic with social work, behavioral health, medical care, addiction counseling/treatment and are able to provide other services as best they can. The staff there actually care, as cliché as it is to say, it’s true, and it makes a world of difference for the patients.
For example, a miserly patient I had met when I was working in the ED was the most grateful and courteous man in the clinic office. Sure, he was still gruff, but the difference was night and day from the way I had seen him previously. Whether it may have been the longitudinal care he got at HCH, or the fact that he was able to spend more time with a provider while not having to wait hours to be seen, the dichotomy of his demeanor from here to the ED was uncanny.
Despite what little resources they have, HCH does incredible work to treat every patient that comes to them, several of whom have been discharged from every other service in the city due to their emotional lability. Even though the facilities leave something to be desired (and with renovations planned for later this year, I hope their accommodations will better mirror their sense of caring) the location of the clinic is extremely important, as there is a shelter directly upstairs.
Even though New Horizons isn’t able to accept as many people due to COVID, several of the patients will simply come downstairs to be seen when they have an issue or a scheduled appointment. As testament to the care they provide at Manchester HCH, many patients who overcome their struggles and find stable housing, jobs, insurance, and the like, still come to the clinic for their primary care needs years later.
Although many patients are able to engage in the clinic, especially with HCH having a separate office that is much more up to date on Wilson Street, there are still those on the fringes of society and who choose to live on their own. Living in the shelters is no easy task. Diseases like lice, scabies and COVID are easily transmitted through the population, regardless of which precautions are taken. In addition, there are plenty of bad influences for those in recovery from substance use when staying in these shelters, and unfortunately, thievery is also a common occurrence in these desperate settings. Although they are safe from the elements, there are still dangers.
During my four weeks a man was murdered by another at a shelter directly across the street from the HCH clinic. The next few days the clinic was dealing with the traumatic fall out of those who witnessed the event or were close with the deceased. One patient even had a ruptured eardrum from being so close to the gunshot. It’s just unfathomable that these people who have already experienced so much loss, can experience even more; it’s a wonder how anyone heals and is able to get their feet back under themselves.
To reach these patients that refuse to go into shelters, and prefer to live on the streets, HCH started a street medicine program to visit these patients where they live. For one to two days a week I would go with one of the providers on street medicine where we would actually visit several tent encampments nestled throughout the city and attempt to contact and provide medical care and services to even the most indignant of “rough sleepers.”
The term rough sleepers refers to people experiencing homelessness who will stay in their makeshift abodes throughout winter, even in the most dire of conditions. Often these people will set up tents and attempt to heat them with propane heaters but stave off the bitter New England cold.
My first day out with street medicine I went with a social worker and a nurse practitioner to a vacant tent encampment. It was on Canal Street just beneath the off-ramp from the Amoskeag Bridge. At least six or seven tents were there, likely more, with some tents having multiple occupants. We were looking for a patient who had bad liver disease that was lost to follow-up. When last seen, they had been looking objectively jaundiced (in advanced liver disease the loss of the ability to breakdown bilirubin, a metabolic by-product, leads to yellowing of the skin and eyes).
I learned my first “street” lesson as we trudged through fresh snow looking for this patient: “we’re only here to help those who want it.” When we announced our arrival outside a tent with “Street Medicine, if you need any medical care or social services we can help,” we were met with some hostility. The occupant of one tent was upset that we would even consider coming near his tent, since this wasn’t the encampment that is apparently infamous for drug use. He told us in no uncertain words that we were not welcome, and we better get away from his tent because he does not use drugs. It was shocking to see that even among the population of people experiencing homelessness, there is considerable prejudice against even prescribers of medication-assisted therapy (MAT). This man was unwilling to even get any medical care or social help because, in his mind, we were conflated with drug users, and he considered us only for that, with no notion that addiction is a disease.
The street medicine team is tough-skinned, and although we were met with hostility they still planned to reach back out a week later to see if the occupant needed any medical care. For a lot of these rough sleepers it takes a significant amount of presence for them to welcome you, so repeat visits can often get people to receive care.
Above: Footage of the fire at the encampment under the Amoskeag Bridge
We were unable to locate the person with liver disease, so we went and did a few house calls of people who were previously experiencing homelessness and attempted to set them up with appointments for their various ailments and to set up COVID vaccinations. Unfortunately, we were never able to return to the Canal Street encampment, because a fire there in early February led to the city shutting down the encampmet a few days later, for safety reasons. At the time rumor some in the encampment had heard was that a person drove by and threw an explosive that caused one of the heating propane tanks to explode and engulf several of the tents in flames. Fire officials later said that there were no explosives involved.
After that incident law enforcement and emergency medical services, including the fire department, closed down the area (understandably) and forced the occupants to relocate, just another kick to these people that are by every sense of the phrase, down and out.
When driving around and visiting other homeless persons, living deep in the woods, in their cars, or in campers spread throughout the city, I was told about a situation that was something I had never considered. As you can imagine, being a rough sleeper isn’t easy to do, especially for those who are older and experiencing homelessness. A person who was struggling with their health and had been rough sleeping for years was finally able to get into housing (there’s a severe dearth in Manchester of housing for these people, so getting an apartment is a small miracle) thanks to the diligence of a social worker at HCH.
However, this individual was finding it difficult to move back into an apartment. Years on the street has de-institutionalized them, so-to-speak. They were worried about not being free and able to be in nature, the only home they have known for the better part of a decade. To me, this story of deinstitutionalization is just plain sad and wrong. It shows me how broken our system is, that after years of homelessness, sleeping in a tent through the most frigid of winter nights year after year, when someone is given housing, they have grown too accustomed to their squalor and have a hard time re-integrating into society. Even though I could get down about this fact, I choose to look at the good, just as the HCH team does.
The Healthcare for the Homeless team is still working with the person, attacking their insecurity from all angles: through therapy, medical care, housing, food stamps, supplemental income, medical insurance and so much more. I remain hopeful that the resolve of these altruists at HCH will make the difference, as I have seen first-hand the difference they do make. Their ingenuity and diligence has made all the difference in the world to people who are often treated like modern-day lepers.
Everyone who works at HCH gets my utmost respect, and I hope that I can help spread similar change when I practice as a physician. I just hope that wherever I wind up for in residency has a similar program that I can help, because although I want to be an Emergency Medicine physician, I know my career won’t be in emergencies all the time, and I hope I can lean on the support of a system that helps patients who fall through the cracks like Manchester Healthcare for the Homeless does.
Sean Byrne is a graduate of Goffstown High School and the University of New Hampshire and is currently studying medicine at the University of New England College of Osteopathic Medicine