Why We Do What We Do
Midwest Street Medicine (MSM) is made up of a remarkable group of individuals, mostly medically trained volunteers but also peer support specialists with lived experience. When people hear about my involvement in MSM they ask what we do and then, often with a puzzled look, they ask why we do it. While what we do can be seen as charity, we would rather describe our work as social justice.
To understand this one must understand not only what we do, but who we serve. We serve the homeless population of Sioux Falls. Per the South Dakota Housing point-in-time count, as of January 2024, there were 610 people experiencing homelessness in Sioux Falls (a 24% increase from 2023), of which 37 were unsheltered, sleeping on the streets. Over half of the homeless community are Native American. Short of those living in a war zone, people experiencing homelessness are the most vulnerable in society, certainly the most vulnerable in the U.S. The experience of the homeless community is complex and poorly understood by the rest of society. People experiencing homelessness suffer from multiple tragedies including poverty, poor education, physical disability, historical trauma, mental illness, cognitive deficits, and chronic medical disease. At least half have endured sexual violence, and three fourths physical violence, often both, often as children, continuing into adulthood. Most have some degree of mental illness, one third of which is severe. Substance use disorder is common, sometimes as the cause of homelessness, sometimes the result, with few receiving treatment despite the desire for such. A number have been released from prison with no resources, at once destined to the streets.
And yet, despite these challenges, there is a pervasive stigma associated with homelessness, that somehow it is their fault, that they do not deserve compassion or aid. Caring for the homeless population has given us insight into where society has gone astray in terms of housing, food security, education, health, and incarceration. There is a serious shortage of social resources, and when available, they are associated with a quagmire of complex paperwork and formalities, often insurmountable to us, let alone to someone living on the street with no resources. Many are unable to work, physically or mentally disabled, but for those who are able, finding work is extremely difficult without a phone, transportation, proper clothing, or personal documents.
Being unhoused is dangerous and deadly, especially for the rough sleepers, (the unsheltered). In addition to increased rates of chronic illness and cancer, they suffer from more accidents and much more violence than the rest of us. The mean age of death in the homeless population is 51, nearly 25 years younger than in the general population. For rough sleepers, mortality is ten times that of the general population and three times that of people who sleep in shelters.
One of the first things people often ask me is: if there is room in the shelters why is anyone sleeping on the street? A number of studies have examined this. First, there is often no room in the shelters, especially on bitter cold nights. It is true that some are permanently banned from shelters due to violating the rules of the shelter: violence, unruly behavior, stealing, but these folks are in the minority. Only one shelter in Sioux Falls is “low barrier”, allowing intoxicated individuals. Some people are banned from the shelters due to chronic illness with shelters unable to meet their medical need. Many who choose to stay on the streets cite fear of theft or lack of safety in the shelters. Some are not mentally capable of making the decision to enter a shelter. Sioux Falls does not have a temporary cold weather shelter or a medical respite center for those not sick enough for hospitalization but too sick to care for themselves on the street. Regardless of the reason, should we allow them to freeze to death? It happens every winter.
So back to explaining why we do what we do. For me personally, I have always relished in the combined art and science of medicine. I love the mental exercise of gathering the relevant information, determining the most likely diagnosis, deciding on treatment, and supporting the patient through the outcome, good or bad. After retiring from my conventional physician role, I found a niche with MSM. Caring for the homeless community is pure basic medicine, harkening back to the days of the country doc. All our visits are “house calls”, in their home, the streets. The visits are one on one, no office, no ivory tower, no computer, no appointment times, no packed clinic schedule. We treat with limited technology. The diagnosis of pneumonia is made without an x-ray, by listening to the patient’s symptoms, taking their temperature, and listening to their lungs with a stethoscope. But there is a huge downside. Modern medicine’s miraculous strides depend on rapidly available tests, procedures, medications, etc., largely unavailable to our patients. About half of our patients have no insurance, half have Medicaid, none have transportation, very few have cell phones, many are simply not capable of arranging care. Preventive treatment, cancer screening, etc. does not exist. Finding care for mental illness and substance use disorder, very common maladies in people experiencing homelessness, is exceedingly difficult. We treat what we can on the street: infections, wounds, mental illness, high blood pressure, substance use disorder, sexually transmitted infection, frostbite. We attempt the arduous task of finding housing because one cannot be healthy without housing. And most importantly, we listen, a skill I will continue to develop for the rest of my life. We listen and we take the time, sometimes a long time, to gain the trust of a person who has been violated so much they feel they can never trust anyone. Our peer support specialists are especially helpful in this regard. We do not judge; we simply provide care.
Our patients are discouraged, stubborn, resourceful, rugged, appreciative, and sometimes feisty. They can be exasperating on the one hand, and delightful on the other. They are no different than you or I except they have been dealt an unplayable hand.
The bottom line is we do what we do because we believe the homeless crisis is an injustice, a failure of society. We believe they deserve a better life and that it is possible to diminish the suffering. We are skilled in providing medical care so that’s what we do. We do what we do because we believe our efforts make a difference, no matter how small.
Robert Santella, M.D.
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