The Charitable Lines of a Broken System: Healthcare for our Most Forgotten Citizens

Frances McConnell

Molly Pringle’s path to Executive Director of Portland Street Medicine is closely tied to her past work in domestic abuse, which has long since been an issue in the United States. According to the CDC, “nearly 1 in 4 women and 1 in 7 men have experienced severe physical violence by an intimate partner during their lifetime” (CDC). What’s often overlooked, however, is the intimate relationship between domestic abuse and houselessness. It’s estimated that approximately 80% of houseless women with children have experienced domestic violence; the ACLU states that advocates have known for years that “the connection between domestic violence and homelessness and suggest ways to end the cycle in which violence against women leads to life on the streets” (ACLU). Pringle began her work at Portland Street Medicine in October of 2019; previously, she had done work at Call to Safety, a crisis hotline for domestic abuse. “One of the top causes of homelessness for women is domestic violence and fleeing an abusive relationship,” she told me, citing this relationship as the reason for her interest in PSM. 

Portland Street Medicine was founded in 2018 by two emergency medicine physicians, a Registered Nurse (RN ), and a Licensed Clinical Social Worker (LCSW), who made it their mission to provide “quality medical care to Portlanders who are facing unstable housing or are sleeping on the streets” (PSM). “In each of their day jobs, they would see folks who were homeless come in for services, usually for things that were really complex because, as you can imagine, someone has a really treatable condition like a cut on their hand, and if they just had access to basic hygiene to clean their wound they wouldn’t get this intense infection that causes this whole cascade of challenges,” Pringle told me. Houseless people “come in with these really complex needs and complex concerns, and then they would be met with barriers. Even if individuals really cared and wanted to offer services, offer support, the systems that they were embedded in just weren’t set up to meet the need.” They took to the streets with tangerines and socks, going from camp to camp and offering their services directly. “And it just took off from there,” said Pringle, “So now we have 125 volunteer providers and those folks span a huge variety of professions. We have nurses, doctors, EMTs, social workers, community health workers, all across the board.” 

So how does a health-focused organization help the people that the United States healthcare system has failed? “What we do is go directly to people, support them in getting connected to care that hopefully feels supportive and healing to them and not traumatizing and can support their unique needs. But that’s really difficult,” Pringle sighed, “That’s really difficult.” The incredible dedication of the volunteers and employees of PSM is evident through their willingness to work towards this difficult goal. “We’re all so committed to this idea that we can do better as a community and that there has to be new ways of caring for one another that we haven’t even conceived of yet. We want to be vulnerable and we want to try together. And this organization embodies that,” said Pringle. I was struck by the word “vulnerable.” To fix a broken system, medical care providers need to understand the power dynamics of the system in which they are operating. To step outside of the hospital and into the houseless community is to recognize that huge chasm that must be crossed in order for the disenfranchised to get the care they need. 

Her goal, throughout the organizations she’s worked with, has been “to literally meet people where they’re at and to be responsive, creative, and relationship based instead of transactional.” For her, that’s what keeps her optimistic; “zooming in on individual relationships is always a nice place to come back to,” she said, “Me and this person, we’re having a caring interaction right now. And that’s enough.” 

* * * * *

One crucial part of the American healthcare system is the emergency department, which plays a critical role in care for the houseless. In the early 1980s the practice of “patient dumping” —in which hospitals would refuse services to patients who couldn’t pay or didn’t have insurance—became common. In response, in 1986, the United States Congress passed the Emergency Medical Treatment and Active Labor Act (EMTALA). This federal law mandates the stabilization and treatment of anyone who comes into the Emergency Department. Many houseless people live in high risk situations with little access to hygiene facilities. Because of this, simple things like a cut on a hand can lead to infections and much more serious problems. Things that many people who are housed may not bat an eye at can quickly become grave issues for the disadvantaged. It’s because of the EMTALA that houseless people are able to receive care in hospitals. Although the emergency department is the most expensive way to access healthcare, it is also the only sure bet for people without insurance. 

Dr. Robert Cloutier is one of the doctors providing such care at Oregon Health & Science University (OHSU) in the emergency department. What got him involved with PSM, he told me, is that the houseless population is “a group of people [he] deals with very frequently in the emergency department, and [he] wanted to be more informed about what [he] could expect from the kind of care [he] renders to them.” He didn’t stop there, though. A big part of his job at OHSU is medical school admissions, where he had the opportunity to talk to prospective and current students as well as read application essays sent in by them. To him, the idea of helping those who need help, not just those he wants to help, is important—and it’s a value he wants to pass along to medical students. “I think what I find with medical students is they all talk about wanting to help marginalized populations. It’s a big buzzword they like to use. And particularly they like to talk about marginalized populations that are far away, you know, Central America, Southeast Asia, Africa, you name it. And for me, Portland Street Medicine is the idea that if you wanna help marginalized populations you can go 100 yards outside of the medical school and there’s a marginalized person right there who needs your help.” He noticed that although students talked about helping the disadvantaged, relatively few followed through. In an attempt to combat this pattern, he created an elective for students there that gave them the option to work with PSM as a part of their pre-clinical rotation. “It’s more of an exposure to understanding marginalized healthcare and marginalized populations than it is for them to get specific clinical goals or clinical skill sets,” Cloutier told me. The elective wasn’t aimed at improving their physical skills, but rather allowing them to grow as people and gain a better understanding of the very people they had talked about wanting to help.

The system itself, says Cloutier, is “entirely wholly dysfunctional, and when we try and get healthcare out on the streets, we are trying to work within a broken system. We are trying to find ways to exploit the charitable lines of the broken system.” The healthcare system in the United States is not designed to care for the people PSM serves: the disadvantaged, the houseless, the uninsured. Every step that he and the volunteers and employees at PSM take in the right direction, towards a more comprehensive and stable form of medical care, is through a manipulation of the resources available to them. Instead of receiving federal or state funding, PSM collaborates with other non-profits around the city in an effort to set their patients up for success. 

These relationships are part of what make the organization unique; it is a direct line of support, designed by people who care and who have a desire to learn and help, who dedicate their time and services to the betterment of the community. “It’s a combination of doing the right thing and wanting to learn about stuff that makes you kind of uncomfortable,” Cloutier told me, “I learned a lot on my first shift when I went out and I was amazed at the depth of my misunderstandings of what constitutes this population.” The way mental health and addiction issues manifest themselves within the houseless population, the way houseless people live, the jobs they have or don’t have, how they ended up houseless—all of these are things that housed people tend to infer without any prior knowledge. The reality is that houselessness looks different for everyone, and that’s part of what makes it so uncomfortable: the knowledge that houseless people are just like you, and you wouldn’t want to be treated the way they are. That’s part of Cloutier’s reasoning for sitting on the board at PSM. His goal is to work to get rid of these misunderstandings and “to be able to create an infrastructure that we can use to learn more about the houseless population in Portland and find ways to help patients solve their problems” 

* * * * *

To Cloutier’s point, it’s not just the houseless community that illustrates how dysfunctional or broken our healthcare system is. The United States has a long, horrifying, and saddening history of prejudice and systematic racism and oppression in medicine, from HIV/AIDS to cancer, prenatal care, and the current COVID pandemic. In 1932, the United States Public Health service conducted the “Tuskegee Study of Untreated Syphilis in the Negro Male” in Macon County, Alabama. “Free Blood Test; Free Treatment, Come and Bring All Your Family,” stated the advertisements that attracted 600 black men to the study. The fact that they would be participating in a 40-year observation of untreated syphilis, however, was left unsaid. The participants were left to die  while believing they were receiving treatment—an indefensible violation of human rights that destroyed “the trust many African Americans held for medical institutions” (DeNeen). An official apology wasn’t issued until 1997; only 8 survivors of the study were alive to hear it. 

In 2019, an algorithm used by US hospitals to allocate health care to patients was found to be systematically discriminating against minorities, assigning them lower risk scores “than [their] white counterparts, leading to fewer referrals for medical care” (Kretchmer). Racial prejudice isn’t the only type of prejudice present in the healthcare system, however. A study of houseless people’s perceptions of welcomeness and unwelcomeness in healthcare encounters published in the Journal of General Internal Medicine interviewed houseless people on how welcome they felt in professional healthcare settings and found many participants “reported intense emotional responses to unwelcoming experiences, which negatively influenced their desire to seek health care in the future.” A recent mixed-methods study on community-derived recommendations for healthcare systems and medical students to support people who are houseless in Portland, Oregon found that houseless people “perceive high stigma in healthcare settings, and face disproportionate disparities in morbidity and mortality versus people who are housed” (King et al.). Firsthand accounts from houseless individuals support the study’s findings.

One houseless person stated they’d “rather sit here and f____n’ die on a bench” than return to a professional setting to receive care and be treated the same way they had been treated in the past. “It makes me [feel] subhuman, like that I don’t really belong in society,” another said, “it was like [I was] a piece of meat” (Chuck et al.). Houseless people already face an unimaginable number of barriers just to get to a place where they can receive treatment— worries about transportation and arriving on time as well as leaving their belongings in insecure environments or being robbed. For many, the idea of seeking professional care is incredibly unwelcome, a result of a lack of trust in the US healthcare system. The study found that most of the participant’s desires could be boiled down to four things: they want medical students and professionals to “listen to and believe them,” “work to destigmatize houselessness,” “engage in diverse clinical experiences,” and “advocate for change at the institutional level.” Participants “asked healthcare institutions to use their power to change laws that criminalize substance use and houselessness, and build healthcare systems that take better care of people with addiction and mental health conditions” (Chuck et al.). And that’s “most of what we do” at Portland Street Medicine, said Pringle, “The folks who are trying to access services, they’re the ones who are experts on what it’s like to go through that process and they know what the barriers are. So we really try and listen, and then we try and reflect that back to our systems so that they can better serve the community.” Portland Street Medicine’s approach is one way of addressing disparities in the houseless community, but the problems are systematic and loom large despite their best efforts.

* * * * *

When you risk losing everything you own just to tend to an infected cut on your hand, you understand why it’s that much more difficult to access healthcare. 

“Homeless camp cleared, boulders in place under North Portland overpass” reads the top headline from my search for “Portland houseless”. Despite having committed to building new permanent and semi-permanent homeless shelters around the city, there remains a discrepancy between the city’s words and its actions. Houseless people don’t disappear when shelters are built. For some, shelters simply aren’t the right place for them. For others, they’ve formed connections and built communities around these camps. When the camps are cleared they lose not only their place of residence, but also any sense of security or normalcy they’ve gained from residing there. A sudden change in location can also make transportation to hospitals or other necessary facilities more difficult. The risk of losing everything just to see a doctor adds to the difficulty.

This type of displacement of houseless people is part of what contributes to healthcare disparities and widens the gap between the houseless population and the rest of the city. Despite these types of efforts from the city, however, it’s not hard to track down the camps Pringle and Cloutier frequent. A study in April, 2021, found Oregon to have the fourth highest rates of houslessness in the United States (Security.org). Nothing stands out about these camps to someone who’s lived in Portland for a stretch of time. For the average person, the goal when confronted with a camp on the sidewalk is to move on. Out of sight, out of mind. But for those who live in camps like these, that’s not exactly an option. 

As I walk down the streets in Northeast Portland I find myself wondering how to pass by the tents that obstruct parts of the sidewalk. It rained that morning, and the water has seeped through the nylon in the places where the material met dips in the ground in which rain pooled. It smelled of cigarettes and wet cardboard, which I discovered came from the sign leaning against one of the tent flaps that had soaked up enough water to the point where the edges had begun to disintegrate. “Homeless—Anything Helps”, it read, “God bless.” What I found to be the most overwhelming, however, was my instinct to look away from the camp—to move away from it. The reason, I suppose, is because as soon as I engaged with the camp and the people living there I also had to admit to myself that it was real. The people in front of me were real people deserving of compassion and kindness and good health and all the opportunities I had been born with—and that they weren’t receiving it. 

The desire to create meaningful change can start by paying attention and of noticing the people around us. What started with four people with tangerines, socks, and a desire to make a difference and offer their services to the disadvantaged has become an official organization with 125 volunteer providers. There are nurses, doctors, EMTs, social workers, community health workers, and more, dedicating themselves to “reaching our most forgotten citizens” (PSM) here in Portland, Oregon. “I see so much resilience and so much care in those communities,” Pringle tells me, “And I just have to believe that we can do better as a community and that there are new ways of caring for one another that we haven’t even conceived of yet, but we want to be vulnerable and we want to try together. And that’s what helps me stay hopeful.” All the good that’s come out of Portland Street Medicine is the direct result of the individuals who were willing to take on the problem of houselessness and healthcare disparities here in Portland—they are working within a system that does not accommodate them so that the marginalized populations within our community are seen and cared for. They made the active choice to stop looking away, to engage with the people around them, and that choice is saving lives.

Works Consulted

ACEP.org. “EMTALA Fact Sheet.” American College of Emergency Physicians, http://www.acep.org/life-as-a-physician/ethics–legal/emtala/emtala-fact-sheet/#:~:text=The%20Emergency%20Medical%20Treatment%20and,has%20remained%20an%20unfunded%20mandate. Accessed 5 June 2021.

ACLU. “Domestic Violence and Homelessness.” American Civil Liberties Union, 2010, http://www.aclu.org/sites/default/files/pdfs/dvhomelessness032106.pdf. Accessed 3 June 2021.

Alhusen, Jeanne, et al. “Racial Discrimination and Adverse Birth Outcomes: An Integrative Review.” National Center for Biotechnology Information, 2017, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5206968/. Accessed 3 June 2021.

Bitterman, Robert. “EMTALA: The Law That Forever Changed the Practice of EM.” ACEP Now, 2018, http://www.acepnow.com/article/emtala-the-law-that-forever-changed-the-practice-of-em/#:~:text=In%20the%20early%201980’s%2C%20dreadful,insurance%20or%20ability%20to%20pay.&text=Congress%20responded%20to%20patient%20dumping,Active%20Labor%20Act%20(EMTALA). Accessed 5 June 2021. 

Blankenship, Kim, et al. “Black-White Disparities in HIV/AIDS:The Role of Drug Policy and the Corrections System.” National Center for Biotechnology Information, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1388265/. Accessed 3 June 2021.

Brandt, Allan M. “Racism and Research: The Case of the Tuskegee Syphilis Study.” The Hastings Center Report, JSTOR, 1978, http://www.jstor.org/stable/3561468?origin=crossref&seq=1#metadata_info_tab_contents. Accessed 3 June 2021.

Brown, DeNeen. “‘You’ve got bad blood’: The horror of the Tuskegee syphilis experiment.” Washington Post, 2017, http://www.washingtonpost.com/news/retropolis/wp/2017/05/16/youve-got-bad-blood-the-horror-of-the-tuskegee-syphilis-experiment/. Accessed 3 June 2021.

Byrd, W., and L. Clayton. “Race, medicine, and health care in the United States: a historical survey.” National Center for Biotechnology Information, 2001, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2593958/. Accessed 3 June 2021.

CDC. “Violence Prevention Infographic.” Centers for Disease Control and Prevention, 2020, http://www.cdc.gov/violenceprevention/nisvs/infographic.html. Accessed 3 June 2021.

CDC. “Tuskegee Study.” Centers for Disease Control and Prevention, 22 Apr. 2021, http://www.cdc.gov/tuskegee/timeline.htm. Accessed 3 June 2021.

CMS.gov. “Certification and Compliance For The Emergency Medical Treatment and Labor Act (EMTALA).” Centers for Medicare and Medicaid Services, http://www.cms.gov/medicare/provider-enrollment-and-certification/certificationandcomplianc/downloads/emtala.pdf. Accessed 5 June 2021. 

Cloutier, Robert. Personal interview. 29 April 2021

Fuller, Alison, et al. “Innovating for a cause: the work and learning required to create a new approach to healthcare for homeless people.” Journal of Education and Work 31.3 (2018): 219-233. Accessed 3 June 2021.

Greater Portland Health. “Healthcare for the Homeless Program.” Greater Portland Health, 2021, http://www.greaterportlandhealth.org/services/healthcare-for-the-homeless-program. Accessed 3 June 2021.

Guilfoyle, John, et al. “Prejudice in medicine.” National Center for Biotechnology Information, 2008, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2592307/#:~:text=For%20the%20purposes%20of%20health,levels%3A%20the%20health%20care%20structure%20(. Accessed 3 June 2021.

Hayes, Elizabeth. “Housecalls for the Homeless.” Portland Business Journal, 8 July 2020, http://www.bizjournals.com/portland/news/2020/07/08/how-portland-street-medicine-went-from-zero-to-ve.html. Accessed 3 June 2021.

ICPH. “The Intimate Relationship between Domestic Violence and Homelessness.” Institute for Children, Poverty & Homelessness, 27 Oct. 2018, http://www.icphusa.org/commentary/the-intimate-relationship-between-domestic-violence-and-homelessness-2/. Accessed 3 June 2021.

KATU. “Homeless camp cleared, boulders in place under North Portland overpass.” KATU, 2021, katu.com/news/local/homeless-camp-cleared-boulders-in-place-under-north-portland-overpass. Accessed 3 June 2021.

King, Caroline, et al. “Community-derived recommendations for healthcare systems and medical students to support people who are houseless in Portland, Oregon: a mixed-methods study.” BMC public health 20.1 (2020): 1-12. Accessed 3 June 2021.

Kretchmer, Harry. “A brief history of racism in healthcare.” World Economic Forum, 2020, http://www.weforum.org/agenda/2020/07/medical-racism-history-covid-19/. Accessed 3 June 2021.

Ledford, Heidi. “Millions of black people affected by racial bias in health-care algorithms.” Nature News, 2019, http://www.nature.com/articles/d41586-019-03228-6. Accessed 3 June 2021.

Lu, Xiao, and Shanxiang Xu. “Important role of emergency department doctors after the outbreak of COVID-19 in China.” BMJ Journals, 2020, emj.bmj.com/content/37/6/334. Accessed 3 June 2021.

McVean, Ada. “40 Years of Human Experimentation in America: The Tuskegee Study.” McGill Office for Science and Society, 2019, http://www.mcgill.ca/oss/article/history/40-years-human-experimentation-america-tuskegee-study. Accessed 3 June 2021.

Nelson, Bryn. “Cancer Cytopathology: How structural racism can kill cancer patients.” American Cancer Society Journals, 4 Feb. 2020, acsjournals.onlinelibrary.wiley.com/doi/full/10.1002/cncy.22247. Accessed 3 June 2021.

Nickasch, Bonnie, and Suzanne K. Marnocha. “Healthcare experiences of the homeless.” Journal of the American Academy of Nurse Practitioners 21.1 (2009): 39-46. Accessed 3 June 2021.

OHSU. “Rob Cloutier, M.D., receives Golden ROSE Award.” Oregon Health and Science University, 2021, http://www.ohsu.edu/school-of-medicine/emergency/rob-cloutier-md-receives-golden-rose-award. Accessed 3 June 2021.

Polner, Robert. “The 12 Biggest Myths about Homelessness in America.” New York University, 2019, http://www.nyu.edu/about/news-publications/news/2019/ september/HomelessQandA.html. Accessed 5 June 2021.

Pringle, Molly. Personal interview. 4 May 2021

PSM. “The Problem.” Portland Street Medicine, 2021, http://www.portlandstreetmedicine.org/the-problem. Accessed 18 Apr. 2021.

PSM. “Medical Care for the Homeless.” Portland Street Medicine, 2021, http://www.portlandstreetmedicine.org/. Accessed 3 June 2021.

Security.org. “State of Homelessness in 2021: Statistics, Analysis, & Trends.” Security.org, 2021, http://www.security.org/resources/homeless-statistics/. Accessed 3 June 2021.

Shortt, S. E. D., et al. “Delivering primary care to homeless persons: a policy analysis approach to evaluating the options.” Healthcare Policy 4.1 (2008): 108. Accessed 3 June 2021.

Social Solutions. “20 Alarming Domestic Violence Statistics.” Social Solutions, 2018, http://www.socialsolutions.com/blog/domestic-violence-statistics-2018/. Accessed 3 June 2021.

Terry, Marisa, B. E. D. I. Gurpreet, and Neil Patel. “Healthcare needs of homeless youth in the United States.” Journal of Pediatric Sciences 2.1 (2010). Accessed 3 June 2021.

Wen, Chuck K., Pamela L. Hudak, and Stephen W. Hwang. “Homeless people’s perceptions of welcomeness and unwelcomeness in healthcare encounters.” Journal of General Internal Medicine 22.7 (2007): 1011-1017. Accessed 3 June 2021.

Wikipedia. “File:Northeast Portland homeless camp tents.jpg.” Wikipedia, 2020, en.wikipedia.org/wiki/File:Northeast_Portland_homeless_camp_tents.jpg. Accessed 3 June 2021.