Reginald is having his blood pressure checked in Edward R. Murrow Park, a tiny triangle of greenery on Pennsylvania Avenue NW three blocks west of the White House. Dr. Catherine Crosland uses a wrist cuff to monitor Reginald’s blood pressure. It isn’t as precise as an upper arm cuff, she’ll admit, but it’s better than nothing. She looks him up on eClinicalMobile, a free mobile app where she learns, based on electronic medical records, that he had borderline high blood pressure in the past.
The two met by chance. But the health checkup is part of Crosland’s “street medicine” practice, for which she walks around select neighborhoods, medical bag in hand, to see if anyone experiencing homelessness needs care. Reginald, who’s been homeless since he was released from prison five or six years ago, just so happened to see Crosland and her team meet with others in the park. Curious about what they were doing, Reginald approached them.
“I never really got a regular doctor to go to,” says Reginald, 46.
“I can be your primary,” replies Crosland.
“Yeah?” he asks bashfully.
By the end of 15-minute conversation, Reginald books himself a next-day appointment with Crosland at Unity Health Care at 425 2nd St. NW, where she treats patients experiencing homelessness on Tuesday and Friday mornings. At the clinic, Crosland will be able to provide a more thorough and private medical exam. (Reginald did attend his appointment and Crosland was able to refer him to a couple of specialists.)
The health checkup in the park served as a reintroduction to the city’s safety net services. Reginald had lost contact with the only health provider he saw in the District, and never met with anyone to go over his housing options. He stopped visiting his provider after his cell phone got disconnected and he lost touch with his case worker. He used to visit a mental health clinic called Community Connections, where he was treated for depression, bipolar disorder, and schizophrenia. At the park, Crosland offered to reconnect him with Community Connections or arrange a visit with one of Unity Health Care’s own psychiatrists or therapists. At the clinic the next day, Crosland referred Reginald to a Unity psychiatrist, his preferred option.
Reginald has been unsheltered for years. He applied for housing while in prison, but nothing materialized. Crosland introduced him to an outreach worker with Pathways to Housing DC, who accompanied her as she did her medical rounds that Monday afternoon, and Reginald agreed to meet with the worker the next day at the park to fill out a housing assessment.
“You are going to have a busy day,” Crosland tells Reginald. “You are going to come see me in the morning and then see her in the afternoon—”
“—I like it like that,” says Reginald.
***
While its clinics now serve all District residents, regardless of their ability to pay, Unity Health Care started out solely caring for patients experiencing homelessness. Founded in 1985, Unity Health Care was one of the country’s first groups to provide health care for the homeless. From the very beginning, its clinics have been based in homeless shelters and since 1987, its doctors have traveled by van to provide care to patients living on the streets.
“We’ve always believed in meeting our patients where they are,” Crosland says.
Unity Health Care started its street medicine practice in 2009 so they could reach more patients. The then-executive director of the Georgetown Ministry Center, Gunther Stern, asked Unity Health Care if Crosland could walk with him as he did outreach around Georgetown instead of staying in the van. While the van started out in a similar vein as street medicine, it had its own limitations.
“Even when we had the van parked next to the park, sometimes people won’t take that first step to come in and see the doctor for any number of reasons—paranoia, fear of doctor … they don’t want to leave their belongings, which are at this corner and you are parked over at that corner,” says Crosland. “We have realized more and more that if we take that first step to engage people in care, we can start building that trust over time.”
Street medicine is practiced in cities all over the country, from Los Angeles to Atlanta. Dr. Jim Withers, who started one of the nation’s first full-time street medicine practices in Pittsburgh, began walking around with medical supplies in his backpack and meeting with patients experiencing homelessness in alleyways or highway overpasses as early as 1992.
Crosland, for her part, has been walking since she started at Unity Health Care more than 10 years ago, and now leads the street medicine practice. She knew she wanted to do this type of work at a young age. Before attending Harvard Medical School, Crosland worked with the global health nonprofit Partners in Health in Peru, where she accompanied health care workers as they delivered therapy to people in their homes. Now, two decades later, Crosland is the director of homeless outreach at Unity Health Care and continues to deliver health care to people where they live. In academia, this is known as “social justice medicine,” but in practice, it boils down to meeting people where they are, quite literally.
Unity’s street medicine practice started in Georgetown but partnerships with homeless organizations allowed street medicine to develop and expand to neighborhoods throughout D.C. like Eastern Market and Golden Triangle. Half of Unity’s funding comes from insurance reimbursement, while the rest comes from the federal government, grants, and private donations. Homeless outreach workers who accompany Unity doctors during their street medicine practice are funded through their own organization or D.C. government agencies like the Department of Small and Local Business Development and the Department of Behavioral Health. The Pathways workers who accompanied Crosland on Monday were paid by the Golden Triangle BID. There is no formal financial agreement between Unity and outreach workers.
Throughout the week, four doctors with Unity Health Care walk five times in total, Mondays through Thursdays. They carry simple tools like an oxygen saturation monitor for someone who is complaining about shortness of breath; basic medication for blood pressure, type 2 diabetes, coughs, and colds; and creams for athlete’s foot and lice in rolling bags they wheel around town. Because primary care visits involve a lot of consultation and coordination, it’s possible to have these conversations outside, especially if that’s a patient’s preference at the time.
Crosland would like for street medicine to have a presence in other areas, particularly in underserved communities in Northeast and Southeast D.C., though the areas where street medicine is practiced are not completely rigid. Crosland is on call a lot. Case workers affiliated with community centers and certified by the Department of Behavioral Health, for example, have called Crosland to other parts of the city when they want a medical opinion on whether or not to involuntarily commit someone to the hospital.
Crosland is contemplating setting up a non-emergency hotline so that doctors designated to walk in a specific area can travel to meet patients located all over the city. Outreach workers would be able to call the helpline as opposed to phoning Crosland directly, which is the protocol now. Crosland is still thinking through exactly how it would work, but demand for something like it exists. While Crosland was walking around Golden Triangle Monday late afternoon, she got a text on her cellphone from one homeless outreach worker in NoMa, who told her about an encamped resident carrying an ostomy bag for bodily waste. The worker was concerned that the person might not have any replacement bags or could lose the bags due to housing instability, and thought Crosland might want to check in.
***
Crosland and a team that includes a George Washington University medical student and two Pathways to Housing outreach workers start their journey at K and 17th streets NW. They’ll walk for the next three hours.
There is plenty of uncertainty when doing outreach as it is not always obvious who is experiencing homelessness. Appearance is not a reliable indicator. The outreach workers know some unsheltered people that stay in downtown D.C., but because homelessness is not a permanent condition and people frequently move in and out of homelessness, outreach workers do not know everyone. It’s possible they may miss someone while walking or mistake someone who’s housed for someone who’s not.
They check on a man who is lying outside of a Corner Bakery Cafe. It’s hard to help him, however, because they can not understand him, even when he tries to say or write his own name. He has no identification card. Crosland checks his vitals but that’s all she can really do.
As they continue, they meet others who do not want medical assistance, which Crosland says may be informed by past experiences. One man experiencing homelessness accuses Crosland of trying to kidnap people for just sitting on a street corner. He rejects any care she offers. Then there’s a woman who is maybe six months pregnant and is polite but guarded. The doctor expresses worry after their meeting because she has seen so many women separated from their children because they were unsheltered. They’ll circle back another day with an outreach worker whom the woman says she knows.
When they land in Edward R. Murrow Park, the team comes across a man who is hunched over in his wheelchair. They learn his name is Joseph and that he was just discharged from the hospital. “You are in pain out here,” Joseph, 70, says. Crosland and her team end up calling a shelter hotline so Joseph can stay inside that night.
“It’s been a productive day,”says GW medical student Samantha Sobelman. She’s been shadowing Crosland for the last three years and doing clinical work, including street medicine, for the last year. “The ultimate goal is to build relationships and have people know us so that if something goes wrong they know where to go. There are familiar faces of people they’ve talked to and they trust.”
While they walk, Crosland says that the outreach workers who are accompanying her are better health providers than she is. They are the ones providing shelter, her thinking goes, and research shows housing stability affects health outcomes. But an outreach worker is quick to say in turn that she needs information about medical conditions to effectively advocate for the housing. A patient’s health history is part of the shelter entry process because the federal government prioritizes housing services based on vulnerability.
“More and more I want to know about how I can better advocate for them to get housing,” Crosland says.
Crosland is not a policy person, by her own admission. But it’s hard to miss the impact policy has on her patients. The remnants of structural racism—like racial discrimination in morgage lending—mean her patients are disproportionately black. This was evident Monday as her team walked around downtown D.C. This is why she cannot help but be involved in advocacy, be it championing ways to end chronic homelessness in D.C.—as many as 1,500 residents in the District experience chronic homelessness any given night—or promoting universal health care—with families nationwide weighing whether to purchase life-saving medication because it’s unaffordable even with insurance. Sometimes people are deciding between health care and housing.
But in her daily work, Crosland sees creating trust between her and individuals who’ve already been failed by the safety-net system by virtue of them being homeless as the utmost important task.
“I really do think that act of taking the first step—especially as a physician and seeing someone in the park—really has an impact on people,” says Crosland. “I will see people all over the city that will say ‘Dr. Crosland’ or ‘you’re my doctor’ or ‘I remember when you came to visit me’—this idea that somebody cares enough to come see you where you are I think is a powerful statement and it moves people to feel more open to get care.”