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TERRY GROSS, host:

My guest Dr. Jim Withers has practiced medicine in dark alleys and under bridges as he's traveled the streets treating the homeless. In 1992 he founded Operation Safety Net to treat homeless people in Pittsburgh. It's one of the nation's first full-time street medicine programs, and has inspired similar programs in other cities. Last month, Dr. Withers established the Street Medicine Institute, a non-profit dedicated to helping communities throughout the world develop street medicine programs. Withers is a doctor of internal medicine.

Dr. Withers, welcome to Fresh Air. Being among the first people to set up a street medicine program, what are the some of the obstacles do you faced in getting something like that off the ground? Or maybe like the rules are established now, but they weren't when you started?

Dr. JIM WITHERS (Founder, Street Medicine Institute): There really wasn't anyone to ask in terms of guidance even if this was a very good idea. Early on, I think I didn't tell the hospital for the first nine months what I was doing because I wasn't sure how they would accept that, and then I finally I confessed that I was doing this work, and I would like sort of support. And that time they were able to give us a small grant, which allowed me to hire some of the homeless guys, formerly homeless guys, as outreach workers, and then get a secretary to sort of organize it all. The record keeping is a challenge, people that gave you different names on different days, acquiring supplies - we used to sort of steal things from a hospital early on, and then that worked itself out a little better later on.

GROSS: So, during that those first few months when you were dressing like a homeless person, was that helpful?

Dr. WITHERS: I think so. But it was amusing because after I got established from the streets, they called me Doc Jim, and one bridge to the next they would sort of refer me to someone else that needed help. And then one day a guy said, Doc, why do you dress so poorly? And I realized maybe I should dress up a little bit so. Then I just got more practical in my outfit.

GROSS: So what do you wear now?

Dr. WITHERS: Just dark clothes, you know cargo pants, and I have a backpack which has gotten much bigger, it has a lot of medical supplies and things in it.

GROSS: Yeah, what do you keep in your backpack?

Dr. WITHERS: Well, the street really has to teach you how to do this sort of thing. And that's really the underlying philosophy, which I think is why within the medical field this is very timely. We need to learn to let our patients and those populations that are need to teach us. So as time went by, I saw people who - they had prescriptions that were melting in the rain that some emergency room had given them. They were coughing and ill, but they couldn't afford them, and they weren't going to tell anyone. So, I realized that I needed to start taking some medicines out to the street. The police were kind of skeptical at first about me, so I worked on that relationship as well. And also, there was, in the very beginning, a certain individual on the street that I think would've taken advantage of me if I had anything that was of any great street value. So I began feeling a little Ziploc bags with medicines that could be very useful - antibiotics, pain medicines that weren't addicting, bandage material.

GROSS: You said initially the police were skeptical of you. What were they skeptical of?

Dr. WITHERS: Well, they didn't really believe I was a physician. I certainly wasn't dressed like one at that time. And it was at night, we were going in to places that - actually we're probably trespassing in a few instances. So, they would stop and ask. And I particularly remember, a guy came up to me, and he handed me a handful of heroin and needles and things and just said, Doc, I want to get off drugs, and handed it to me. I looked down the street there was a policeman watching us. And so, there really wasn't any precedent for them, but I got to know some of the police pretty quickly and I actually went to the station and talked to them and acknowledged the hard work that they were doing and made partnerships with them, so that worked out pretty well.

GROSS: So what happened, did you take the heroin?

Dr. WITHERS: I gave it back. I said you're going to have to get rid of this yourself.

GROSS: What are the typical problems you've seen on the street - medical problems - since you started doing this work?

Dr. WITHERS: Well, we live in a part of the country that's cold, and so we do see people who suffer from frostbite, the loss of toes, and trench foot. There's a lot of trauma. People are injured a great deal on the streets just by living out there, but also people are victimized by non-homeless people, actually more often and seriously than by other homeless people. But for the vast majority people, its medical conditions that we all suffer from but just go untreated due to the living circumstances.

GROSS: Are there certain medical conditions, medical problems, that arise from sleeping on a heating vent, on a steam vent, because a lot of homeless people in cold cities sleep on those steam vents on the sidewalk and - I mean it's almost like they're going to get cooked.

Dr. WITHERS: Yeah, they do seem to suffer a lot of bronchial illnesses. I'm not sure that the steam itself is dangerous. What I do see happening is that to stay warm they have to be on the steam grates, and then they get wet. So then if they get away from that area they're going to be warm, and then they get hypothermic or they get more inclined towards susceptibility to the cold.

GROSS: Do you try to convince people not to sleep on those heating vents?

Dr. WITHERS: Well, no. I mean, for those people it's really a matter life or death, we try to give them maybe things that will - that they can change into later or things that will maybe insulate them a little bit from the dampness.

GROSS: Many homeless people are mentally ill, and are suffering with delusions and hallucinations. How do you treat someone in that condition? You don't have their medical records, there's no family members to tell you about pre-existing conditions, they're not going to be able to accurately communicate their symptoms or their, you know, long-term medical problems. So what do you do to get oriented to their problems and to communicate to them what they need to do?

Dr. WITHERS: I'm a general internist. I've sort of had to pick up some psychiatric and psychological experience as I went along here obviously. But you're very limited due to the fact that the person isn't necessarily going to reveal their own background with that. Often times you ask them, what medicines have you been on, and they'll mention some psychiatric medicines so you know that's probably part of the history. But you have to be very indirect because it's very threatening to people to go right to mental-health issues. There's a big gap between the mentally ill of, certainly in the United States, it's probably global, and the bottom run of the latter for mental health treatment. And that gap has still not being closed very effectively. We find ourselves in the middle of many of those kinds of circumstances where the person just can't get to the first stage of treatment or housing or other issues that they need.

So I found that even if a person is quite paranoid, delusional, and afraid, they still have a rich emotional life, and they do understand that you care about them, that you're consistent, that you're respectful. These are things that send powerful messages. And even a very mentally ill person generally responds to these over time. There's a whole art form with working with people over time, and I am become quite amazed that how many people actually do respond to that. Once you've set that sort of a relationship background then you gain much more influence so that you can gently ease people into housing, which we found is probably the best first step, and we have a great supportive team that follows them. And then they're more likely to accept mental health treatment.

GROSS: One of the things you have to do now to institutionalize somebody who's mentally ill is to prove that they're a threat to themselves or others. And what exactly does that mean? I mean if somebody is so disoriented and so out of touch with reality that they can only live on the street and that they don't even understand they're sick, is that a threat to their own health? Is that - does that qualify?

Dr. WITHERS: Well, it is. It is definitely a threat, particularly when there's a weather change, etcetera. But, you know, the average rate life expectancy of a street person is somewhere around 45 to 47 years old. And so you know, it's a - if you want to call it a lifestyle, it's one with a very high mortality rate. The issue then becomes who do you try to target in terms of getting them off the street? And what we found when we begin taking people off the street was that they would come in, either dismissed that night back into their refrigerator box in the snow, or they were admitted for two or three days and then discharged back to the street. And at that point they wouldn't talk to us anymore, so we realized that we really couldn't jeopardize our relationship long-term with street people by just using that tool over and over again.

GROSS: Did you worry about protecting your own safety when you're on the street?

Dr. WITHERS: Well, when I started, basically it was just me and a formerly homeless person. I was quite concerned about my safety. We've been at this for over 16 years, and no one has ever been assaulted or hurt by any homeless person. But the first year was probably a little bit more up for grabs. I had three people point guns at me. I had someone threaten to cut my throat. And it really became obvious to me after time, that we had become part of the street culture and vice versa, and if anything, we were well respected and cared for in the street.

GROSS: So when people held guns to you, were they other homeless people, or not?

Dr. WITHERS: Well, one was a fellow that we came up on the wrong way, and there's a lot of street etiquette and ways of doing things. You really need someone who knows the street, and I would say anyone who is going to do this needs their own ambassadors to the street, formerly homeless are great types of folks to do that. And that person we just surprised.

One guy, I also surprised, he knew me well, but he pulled a shotgun out, and another former homeless guy was able to redirect that, it didn't go off. One was a policeman who pointed the gun at us, and that frightened me more than any because I knew their aim was good, and I didn't move a muscle. So those are the kinds of things, you know, you just have to be careful how you approach people in remote camp sites and things like that.

GROSS: Yeah, you said, you have to be careful not to do it the wrong way. What's an example of the wrong way that got you into trouble or, you know, got a gun placed to your head?

Dr. WITHERS: Well, right, right. The one where I can say we clearly made a mistake was, there was a guy who was nodding, and for whatever reason, we - he was against a wall, and we came at him in a sort of a horseshoe pattern. So he was surrounded, which you know, there's a lot of predators out there that take advantage of the homeless, and I guess that would be the way that they would assault someone. And particularly if someone's dozing, you want to - or you're not sure, you want to yell ahead of time and let them know who you are, what your intentions, and if they wave you off, then you just go away.

GROSS: Now, you said, you know, that it's important in working with people over time to, you know, understand who they are and understand what their delusions are and everything. But is it difficult to work with people over an extended period of time? Do the homeless people that you see stay in one place? Can you find them after their first treatment?

Dr. WITHERS: It is a little challenging. I work with a lot of other cities throughout the United States to help them start programs or to improve the programs that they're doing in street medicine, and one of them had an interesting term, instead of calling it case management, he called chase management. So there's a lot of effort that's put into keeping tabs on people and knowing where they are. Our electronic medical records allows you to put a name in and find out who's likely to know where that person is. We work with the morgue, we work with the libraries, and then the street has its own sort of network of knowing where people are and what's going on with them.

GROSS: My guest is Dr. Jim Withers, founder of Operation Safety Net, which treats homeless people in Pittsburgh, and the Street Medicine Institute, a new non-profit dedicated to helping communities around the world develop street medicine programs. We'll talk more after a break. This is Fresh Air.

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GROSS: If you're just joining us, my guest is Dr. Jim Withers, and he's the founder of Operation Safety Net, which is one of the nation's first full time street medicine programs. It's affiliated with the Pittsburgh Mercy Health System, and Dr. Withers is on the teaching faculty there. I know you mentioned that you see a lot of medical problems that, you know, are in the rest of the population, but will get treated with people who aren't homeless, but will remain untreated and will therefore be exacerbated, I know, among homeless people. But are there medical problems that you see on the street that you don't see anywhere else? Problems that have basically you know been eradicated in other places?

Dr. WITHERS: The street folks are - their nutrition's poor, their condition is poor, and so they're sort of like the canary in the cave, I think, in terms of diseases, and that's another reason to keep a close eye on what's going on with them. The illnesses that you see on the street that you wouldn't typically see amongst the general population would be complications, again. I've seen more than my share of maggot infestations and lice and those kinds of illnesses which, frankly, I just haven't seen too often outside of that setting. But at least in this country, for the most part, street people don't have that many illnesses that are unique to them.

GROSS: Dr. Withers, you organized the first international street medicine symposium. You organized it in Pittsburgh where you work. What are some of the things you learned from talking to doctors who practice street medicine in other countries?

Dr. WITHERS: Well, in some places, the definition of what's homeless is a lot more difficult to pinpoint. If you're in India, for example, and someone's living in a hovel if they're living in a lean-to, if they're sleeping on the street, and they're still working as a rickshaw operator, I mean, the gradation there is so much more gradual. Here in America, if you're homeless, you're not really one of us anymore. And in places like Katmandu and Calcutta, it's hard to necessarily to draw that line.

I would say, probably leprosy in India would be equivalent because those people are still stigmatized and rejected by society the way our homeless are. In Europe, I've noticed that, at least in Northern Europe, and it may be linked with the nature of their society or maybe it's the accessibility of health care, they just don't have the street populations that we do. It seems like the entry level is much easier for the services in terms of mental health and drug treatment. I think that has made a big impact there.

GROSS: Dr. Withers, I understand you started a wall in memory of homeless people who you've worked with who have died. Would you describe the wall?

Dr. WITHERS: Years ago, I was in a People Magazine article, and Sidney Sheldon sent some money. It was very kind of him, and I thought I know what this money should go for. There were people dying on the streets and no one was remembering them. So I used the money to buy 10 plaques, and I was going to drill them into the sidewalk or wherever that person had slept, and slowly they would accumulate and they would make a - almost a political statement about how many people are dying.

Well, it turns out that that's illegal, so we negotiated with the city, and we found a compromise of a wall that is used, and ever since 1989 actually, we've had every street person that we can account for has a plaque on that wall, and it's become a - one of the other focal points for a sense of community. The homeless anticipate their friends' names appearing there when they've died. Family members come, and it's a place of healing and of acknowledging also the reality of what's going on. Each year, as in other cities, we have a homeless memorial service on December 21st, and it's a candlelight service, and it has great meaning for all of us.

GROSS: Sounds like those plaques are part obituary, part tombstone.

Dr. WITHERS: That's right.

GROSS: Well, I want to thank you very much for talking with us.

Dr. WITHERS: Thanks for raising awareness.

GROSS: Dr. Jim Withers founded Operation Safety Net which treats homeless people in Pittsburgh, and the Street Medicine Institute, a new program dedicated to helping communities around the world develop street medicine programs.

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GROSS: You can download podcast of our show on our Web site, freshair.npr.org.

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