“A mile from here, people are experiencing the same health disparities as they have in Third World countries,” said Dr. James O’Connell, founder and president of Boston Health Care for the Homeless Program (BHCHP) and Assistant Professor of Medicine at Harvard Medical School.
“It’s the end result of weaknesses across our sectors. We will only solve it when people say that this is a problem we all have. We need to look at it from an architecture, city planning, and public health point of view,” he said.
Dr. O’Connell’s work to address the needs of the homeless population in Boston began soon after receiving his medical degree from Harvard University and completing his residency in Internal Medicine at Massachusetts General Hospital (MGH). He noted that after finishing his residency and working in the Intensive Care Unit (ICU) at MGH, he was confident that he could handle anything.
Then he went to work at a clinic in the Pine Street Inn homeless shelter.
“It was sheer chaos,” he recalled. “I was paralyzed, because I had control over nothing and didn’t understand anything.”
Dr. O'Connell realized that the training he had received at MGH was ineffective for addressing the needs of homeless people.
“I was trained to have 15 minute appointments [with each patient], get to the point quickly, and move on. But you won’t get any homeless person to share anything in 15 minutes; you have to take time,” he said.
And so began a new, unexpected era of his medical education, directed by the staff at the shelter.
“Everything I tell you today, I learned from nurses and social workers,” he said. “For the first two months [at the clinic], they made me soak the patients’ feet. That was how they taught me to be quiet and respectful. I was at their feet — it was a definite power flip, and certainly altered my ego.”
From that perspective, he said, “I watched the nurses work their magic.” He noted how the nurses would say their patient’s names gently, and use great patience to administer care.
“There was one man I had seen in the emergency room at MGH,” he recalled. “He had been brought in by the police, and was considered treatment resistant. At the clinic, I soaked his feet for a month. [One day] he said, ‘I thought you were a doctor?’ He was the first person [at the shelter clinic] to acknowledge that I was a doctor! Then he asked for help to sleep. A month later, he was taking all of the medications that he had been resisting over the past 20 years.”
Providing Medical Care to the Homeless
In 1985, O’Connell was the founding physician of a program to support the people experiencing homelessness in Boston. The program received funding through a four-year grant from the Robert Wood Johnson Foundation and the Pew Charitable Trust.
“We needed to have homeless people on the advisory board, to tell us how they wanted to be served,” he said. “That board was the best thing that ever happened to us.”
The board emphasized the importance of continuity of care for the homeless community. They also made a distinction between social justice and charity work.
“When they had the chance to set up their own healthcare system, they wanted it to be based on social justice,” he said.
Specifically, they didn’t want to rely on the labor of volunteers who could leave at any time, as can happen with a charity-based program.
“After we had paid our dues, then we could bring in volunteers,” recalled O’Connell.
In addition to his full-time clinical work with homeless individuals in the program, O’Connell also established the nation’s first medical respite program in the Lemuel Shattuck Shelter, and later worked with MGH to design a digital medical record system for the homeless. In addition to his own publications, his work at BHCHP is the subject of New York Times Best Seller, Rough Sleepers: Dr. Jim O’Connell’s Urgent Mission to Bring Healing to Homeless People by Tracy Kidder (Random House, 2023).
Honoring the Wishes of Homeless Patients
As featured in the book, O’Connell recalled his interaction with Santo, a man with a loud laugh who came to the shelter clinic with a unique complaint. “He said, ‘I can’t swallow vodka anymore.’ As I talked to him, I learned that he hadn’t been able to eat for weeks, but it was when he couldn’t get the vodka down that he had to go to the doctor.”
Santo was later diagnosed with esophageal cancer. Ultimately, O’Connell was faced with finding a safe place for Santo to die.
“I spent a weekend visiting nursing homes and finding him a place for hospice. I thought I had done something good. Then I came back to the Pine Street Inn two days later and heard his laugh,” he said.
O’Connell found Santo in the shelter, sitting with all of his friends, laughing, and pouring vodka into his feeding tube. When he questioned him about hospice, Santo shared his perspective.
“He told me, ‘I appreciate all you’ve done, but I didn’t know anyone there. I don’t want to die there. I want to die with my friends.’”
After that, they arranged end of life care for Santo at the shelter. “I had never thought to ask him what he wanted,” said O’Connell. “I have since learned that I have to listen to what people want.”
Serving the Homeless through Mobile Units
That listening and lack of judgment are key to O’Connell’s success in providing medical care to this often overlooked community. He started working in the BHCHP Mobile Unit to offer care to the homeless who wouldn’t come to the shelter, even when they needed medical attention.
“Tonight in Boston, 95% of the people who are homeless will be in a shelter,” said O’Connell. “The folks who are outside are a distinct subgroup of the homeless population. They are choosing not to be in an 800-bed shelter.”
Due in many cases to psychiatric issues and paranoia, these people feel that staying outside is the only option for them.
While the initial idea was to create a medical van, the people they visited requested food and blankets. Providing these resources built trust between the staff in the van and the homeless community. The van began daytime routes as well, which led to yet another realization.
“Eighty percent of [what we do in the clinic] could be done on a park bench or at a McDonalds,” said O’Connell. “We learned we could do a lot of stuff with someone who resisted going to the hospital.”
With a little privacy, they met with homeless people where they were already comfortable and spending most of their time: be it the park, a Burger King, or in South Station. The staff monitored heart issues, administered blood tests, and checked weight, reaching people who had been written off as resisting care and treatment.
“They weren’t treatment resistant,” said O’Connell, “just resistant to the way we treated them.”
The van was especially useful when COVID–19 hit. While 75% of the homeless population in shelters contracted the virus, the people on the streets mostly avoided infection. When the vaccine was released, the van visited the park where many homeless people spent their time.
“They all accepted the vaccine,” said O’Connell. “They had seen people get sick. Also, they were being offered the shot by people they had known for a long time. If we had told them to go to the clinic to get the shot, they probably wouldn’t have done it.”
Delivering Healthcare is a ‘Team Effort’
Without the van, they may never have connected with Michael, who wouldn’t visit the shelter but often sought out the van for the sandwiches. O’Connell described Michael’s overlapping traumas, noting that the “lack of care and too much trauma as children,” is common among people living on the streets. When Michael needed chemotherapy and radiation for metastatic prostate cancer, O’Connell knew that providing treatment alone wasn’t enough, as shelters are closed during the day.
“If you’re on chemo and your days are spent walking around outside, it’s almost impossible to tolerate,” said O’Connell.
The BHCHP Medical Respite program offers a place for people to stay if they aren’t sick enough to stay in the hospital but have no other place to go. Michael stayed there throughout his cancer treatment.
“I visited him that evening,” recalled O’Connell. “He was smiling, because he had a bed, nurses, staff, three meals a day, and a TV. He said to me: ‘Doc, it doesn’t get any better than this.’…[Michael] was able to find great joy out of small things in life. We have so much, but we don’t often find joy in it. ”
Once his treatment was over, Michael stayed at the Stacy Kirkpatrick House, another “step-down facility,” helping patients transition between their hospital stay and returning to the shelter. There, a visit from therapy dogs revealed that Michael loved animals. When the staff were able to find him a place to live, he stopped at an animal shelter to adopt a cat. Years later, when Michael’s cancer returned, he refused to go to the hospital because he wouldn’t leave his cat alone. A physician took the cat in so that Michael could enter the hospital for pain medication the week before he died.
“Taking care of Michael was a 38-year journey,” said O’Connell. “It took an adapted healthcare system to take care of him. It was a team effort. That is what I mean by bringing everyone together — doctors, nurses, social workers — to fix this problem. That’s what Simmons is doing, getting all the disciplines together.”
This talk is part of The London Center for Community Engagement and Social Justice's Leadership In Social Justice Series focused on homelessness and the housing crisis. Stay tuned for more events and ways to get involved this spring. Interested in getting involved directly with Boston Health Care for the Homeless Project? Explore volunteer opportunities.