Herman Ware sits at a small, wobbly table inside a large van that's been converted into a mobile health clinic. The van is parked on a trash-strewn, dead-end street in downtown Atlanta where homeless residents congregate.
Ware is here for a seasonal flu shot.
"It might sting," he says, thinking back on past shots.
Ware grimaces slightly as the nurse injects his upper arm.
After filling out some paperwork, he climbs down the van's steps and walks back to a nearby homeless encampment where he's been living. The small cluster of tents sits below an interstate overpass, next to a busy rail line.
Ware hasn't paid much attention to his medical needs lately, which is pretty common among people living on the street. For those trying to find a hot meal or a place to sleep, health care can take a backseat.
"Street medicine" programs, like the outfit giving Ware his flu shot, aim to change that. Mercy Care, a health care nonprofit in Atlanta, operates a number of clinics throughout the city that mainly treat poor residents, and also has been sending teams of doctors, nurses and other health care providers into the city's streets since 2013. The idea is to treat homeless people where they live.
This public health strategy can now be found in dozens of cities in the U.S. and around the world, according to the Street Medicine Institute, which works to spread the practice.
Building relationships to give care
Giving shots and conducting exams outside the walls of a health clinic comes with unique challenges.
"When we're coming out here to talk to people, we're on their turf," says nurse practitioner Joy Fernandez de Narayan, who runs Mercy Care's Street Medicine program.
A big challenge is getting patients to accept help, whether it comes in the form of a vaccination or something simpler — like a bottle of water.
"We'll sit down next to someone, like 'Hey, how's the weather treating you?' " she says. "And then kind of work our way into, like, 'Oh, you mentioned you had a history of high blood pressure. Do you mind if we check your blood pressure?' "
The outreach workers spend a lot of time forging relationships with homeless clients, and it can take several encounters to gain someone's trust and get them to accept medical care.
Their persistent encouragement was helpful for Sopain Lawson, who caught a debilitating foot fungus while living in the encampment.
"I couldn't walk," Lawson says. "I had to stay off my feet. And the crew, they took good care of my foot. They got me back."
"This is what street medicine is about — going out into these areas where people are not going to seek attention until it's an emergency," says Matthew Reed, who's been doing social work with the team for two years.
"We're trying to avoid emergencies, but we're also trying to build relationships."
"Go to the people"
The street medicine team uses the trust they've built with patients to eventually connect them to other services, such as mental health counseling or housing.
Access to those services may not be readily available for many reasons, says Dr. Stephen Hwang, who studies health care and homelessness at St. Michael's Hospital in Toronto. Sometimes the obstacle — say, lacking enough money for a bus ticket — seems small, but is formidable.
"It may be difficult to get to a health care facility, and often there are challenges, especially in the U.S., where people don't have health insurance," Hwang adds.
Georgia is one of a handful of states that has not expanded Medicaid to all low-income adults, which means many of its poorest residents don't have access to the government-sponsored health care program. But even if homeless people are able to get health coverage and make it to a hospital or clinic, they can run into other problems.
"There's a lot of stigmatization of people who are experiencing homelessness," Hwang says, "and so often these individuals will feel unwelcome when they do present to health care facilities."
Street medicine programs are meant to break down those barriers, says Dr. Jim Withers. He's medical director of the Street Medicine Institute and started making outreach visits to the homeless back in 1992, when he worked at a clinic in Pittsburgh.
"Health care likes people to come to it on its terms," Withers says, while the central tenet of street medicine is, "Go to the people."
Help, with respect
Mercy Care in Atlanta spends about $900,000 a year on its street medicine program. In 2018, that sum paid for direct treatment for some 300 people, many of whom got services multiple times. Having clinics on the street can help relieve the care burden of nearby hospitals, which Withers says don't have a great track record when it comes to treating the homeless.
"We're not dealing with them well," Withers admits, speaking on behalf of American health care in general. In traditional health settings, homeless patients do worse compared to other patients, he says. "They stay in the hospital longer. They have more complications."
Those extra days and clinical complications mean additional costs for hospitals. One recent estimate cited in a legislative report on homelessness suggested that more than $60 million in medical costs for Atlanta's homeless population were passed on to taxpayers.
Mercy Care says its program makes homeless people less likely to show up in local emergency rooms and healthier when they do — which saves money.
It's past sundown when the street medicine team rolls up to their final stop: outside a church in Atlanta where homeless people often gather. A handful of people have settled down for the night on the sidewalk. Among them is Johnny Dunson, a frequent patient of the street medicine program.
Dunson says the Mercy Care staffers have a compassionate style that makes it easy to talk to them and ask for help.
"You gotta let someone know how you're feeling," Dunson says. "Understand me? Sometimes it can be like behavior, mental health. It's not just me. It's a lot of people that need some kind of assistance to do what you're supposed to be doing, and they do a wonderful job."
Along with the medical assistance, the staff at Mercy Care give every patient big doses of respect and dignity. When you're living on the street, it can be hard to find either.
This story is part of NPR's reporting partnership with WABE and Kaiser Health News.
ARI SHAPIRO, HOST:
When you're homeless, it's not easy to see a doctor. That's where street medicine comes in. It's an emerging practice, and it can be found in dozens of cities, including Atlanta. That's where Sam Whitehead of member station WABE followed a medical team that visits patients living on the streets.
SAM WHITEHEAD, BYLINE: It's late afternoon, and a van filled with medical supplies idles near an interstate overpass in Atlanta. Herman Ware is getting a flu shot.
HERMAN WARE: Oh, it might sting. Yup, I figured that (laughter).
WHITEHEAD: Ware filled out some paperwork, and a nurse wishes him well as he heads back to the nearby homeless encampment.
UNIDENTIFIED NURSE: Take care.
WARE: I will.
UNIDENTIFIED NURSE: Got that flu shot out the way.
WARE: Yeah, all right.
UNIDENTIFIED NURSE: (Laughter).
WHITEHEAD: This is street medicine. Four days a week, Mercy Care, a local health clinic, sends teams to spots in the city where homeless people gather. Nurse practitioner Joy Fernandez de Narayan runs the program.
JOY FERNANDEZ DE NARAYAN: When we're coming out here to talk to people, we're on their turf.
WHITEHEAD: That means she can never assume anyone wants her help, whether that's a vaccination or something simpler like a bottle of water.
FERNANDEZ DE NARAYAN: We'll sit down next to someone like, hey, how's the weather treating you? - and then kind of work our way into, like, oh, you mentioned you had a history of high blood pressure. Do you mind if we check your blood pressure?
WHITEHEAD: She says it can take several encounters to gain someone's trust and get them to accept medical care. That persistence is how the team helped Sopain Lawson recover from a foot fungus she caught while living out here.
SOPAIN LAWSON: So I couldn't walk, had to stay off my feet. And the crew - they took good care of my foot. They got me back.
(SOUNDBITE OF TRAIN PASSING)
WHITEHEAD: Matthew Reed has been doing social work with the team for the last two years out here among the sounds of trains and rapid transit lines.
(SOUNDBITE OF TRAIN HORN SOUNDING)
MATTHEW REED: This is what street medicine is about is, like, going out into these areas where people are not going to seek attention until it's an emergency, so we're trying to avoid emergencies. But we're also trying to build relationships.
WHITEHEAD: Those relationships can also connect people to other services such as counselling or housing. Dr. Jim Withers is medical director of the Street Medicine Institute, which works to spread the practice. Withers started making house calls to the homeless with a clinic in Pittsburgh in 1992.
JIM WITHERS: Health care likes people to come to it on its terms. And the philosophical central point of street medicine is go to the people.
WHITEHEAD: Doing that work in Atlanta costs Mercy Care about $900,000 a year. The street medicine team gave direct treatment to some 300 people in 2018. Many of them got help multiple times. That helps traditional hospitals, which Withers says aren't great at treating the homeless.
WITHERS: They're still sick. They're still coming to the emergency rooms, and we're not dealing with them well. And we're - they stay in the hospital longer. They have more complications.
WHITEHEAD: And that isn't cheap. One recent estimate says Atlanta's homeless population racked up more than $60 million in medical costs that were passed on to taxpayers. Mercy Care says their program makes homeless people less likely to show up in local emergency rooms and healthier when they do. That's good for them and for taxpayers.
(SOUNDBITE OF TRAFFIC PASSING)
WHITEHEAD: It's twilight. The final stop for Mercy Care's team is a church in Atlanta. A handful of people settle down for the night on the sidewalk. Among them is Johnny Dunson, a frequent street medicine patient. He says the team helps everyone who needs it.
JOHNNY DUNSON: You got to let someone know how you’re feeling, you understand me? Sometimes, it can be like behavior, mental health. It's just not me, you understand me? It’s a lot of people that just need some kind of assistance to do what you’re supposed to be doing, and they do a wonderful job.
WHITEHEAD: Dunson says the street medicine team gives him help and respect. He says living out here, it can be hard to find either.
For NPR News, I'm Sam Whitehead in Atlanta.
(SOUNDBITE OF MUSIC)
SHAPIRO: This story comes to us from NPR's reporting partnership with WABE and Kaiser Health News.
(SOUNDBITE OF MUSIC) Transcript provided by NPR, Copyright NPR.