An Option to Cure

“Dr. Silk, you have to come help me, man. I can’t live like this.”

Not a call that a physician wants to receive.

Juan had been living in supported housing after being homeless for years. His situation was still dire despite now having housing. He had recently had multiple surgeries with drains and an ostomy bag. He needed daily wound care, nutritional supplements, and antibiotics. His apartment had been neglected by the landlord. The ceiling was caving in. The toilet was no longer working. He did not have a doorbell, so nurses and supplies could not get to him. I had known Juan since we first met at a food pantry years earlier. He was struggling with opioid use, but he sincerely wanted to get better. He came regularly to see me. We formed a bond, and I was able to get him to come to our office to receive primary care at Worcester Healthcare for the Homeless.

My attempts to see him at home were to try calling when he had a cell phone, and when it worked. Other times, I would call at his window from the backyard or toss pebbles gently against his window to get his attention. He would come to the window, eventually let me in, and I would do my best to tend to his wounds. I brought him medications, Ensure that I purchased, and supplies that I acquired through donations.

A case worker from my office, Jane, was equally creative. She found ways to help Juan meet his basic needs. She was not going to tolerate the squalor, however. She insisted that we set up a meeting with his case worker, their boss, the landlord, and whomever else could make change to his setting. This was unacceptable.

Juan used opioids. This meant that people looked at him differently. His needs were looked at as questionable. Afterall, he was high most of the time, wasn’t he? Would he even notice the ceiling stains, water damage, and sagging panels? Jane was having none of it. She knew he deserved better. She would see that his conditions were improved. How could he heal in such an unsanitary situation?

We met with all the people who could make decisions. We were assured his situation would improve. The toilet would be fixed, as would the ceiling. A wireless doorbell would be installed that week.

Six months later I ran into Juan’s brother. He came to see me at the mobile van I now worked on (Road to Care), where we provided care for people who are street homeless and often with substance use disorder. Nothing had changed. Juan’s brother was distraught.

“You said they were going to fix it.”

How could I explain? Jane and I had been reprimanded for our efforts by our employer. She quit. Soon after I was let go. The meeting with human resources had listed a slew of infractions including all the efforts to help Juan –meeting with housing leadership without approval, taking medications and supplements to the patient’s house, visiting patients at home. I had shown signs of depression too. That was the final draw. The termination letter from the CEO of family health center read: Based upon the nature of the conduct, there is no option to “cure” under these circumstances.

I was immediately cut off from Juan. What would happen?

Now I knew. Nothing.

I assured Juan’s brother we would re-engage even though he was housed – someone had to. Juan was in the hospital. After our care was severed, he had become worse, and his bowel became infected.

This is not a story about me. This is a story about Juan and the thousands like him in Worcester County. They receive inferior care. And when we turn on each other as providers, even less.

There is no option to cure Juan and those in the same situation based on the current nature of our conduct. We need to work together. We need to support providers who care deeply about the homeless. We need to help those at risk for burnout. More importantly, we need to create more very affordable housing, that comes with wrap-around services including primary care, mental health, social services and peer support.

We also need to offer our respect for everyone in Juan’s situation. He does not receive the same care I receive when he enters the emergency room or hospital. My adult daughter recently joined our team to help with some evaluation. After a few days she said, “I will never look at someone who is homeless the same way again.” We can’t all get to know people who are homeless or have substance use disorder. So, you will have to take it from me, and my daughter: the vast majority of people who are homeless have suffered from many traumas – from before birth, in their childhood, and throughout their lives: rape, incest, violence, poverty, war, mental health disorders, and more. Trauma leads to self-harm, substance use, homelessness – and it becomes a vicious cycle. Society adds to it by staring, pointing, and neglecting. Our Supreme Court has added to it by saying it is illegal to be homeless and arresting people who have nowhere to go. And we, the health care industry, make it worse when we abandon people or treat them differently than everyone else. Layer upon layer of trauma.

We can do better. Let’s treat each other better and treat those we don’t know with some curiosity, compassion, and patience. Maybe we can’t cure this problem in its entirety. But there is an option to cure. We have to choose that option. And all along the pathway to cure is where good things can happen. Those moments of respect and care – just may be the cure. The cure may not be getting 100% better. A famous Jazz musician once said, “all the way to heaven, is heaven.” The cure may be the route to getting better: being treated better, feeling better, trusting better, living better. I have faith that we can do that, together.

Hugh Silk, MD, MPH, FAAFPVice Chair of Community Health and Professor University of Massachusetts Chan Medical School, Department of Family Medicine and Community Health