Outside influences

Healing happens through connection
Photography by
Martha Rial

Left to right: Street Medicine at Pitt members Kathleen O’Connor, Julia Lam and Helena Oft (plus Oft’s dog, Junie B. Jones) head to rounds among people without homes in Downtown Pittsburgh.

One Wednesday last July, Julia Lam spent the evening as she usually does: heading to Downtown Pittsburgh with a group of students and faculty from the University of Pittsburgh, meeting people without homes.

Equipped with food, clothing and supplies to hand out, they walked the streets striking up conversations. Some of the talks led to medical assistance; in other cases, the group shared information about local housing resources. Eventually, a man rushed up to them in distress.

Eyes immediately fixed on a large gash on his leg—it looked like it needed attention. But the man had something else on his mind. “I need to find my bus, because it’s leaving soon,” he hurriedly explained. The man had somewhere to stay that night but would likely have to sleep on the street if he didn’t catch the bus. 

The open wound called out to the group like a blaring fire alarm. But at that moment, the man’s needs lay elsewhere. The crew put aside their initial impulses and rushed him toward the bus stop.

“It goes against all of your instincts,” says Lam, a doctoral student in occupational therapy, “but that’s really the nature of street medicine: putting what we as providers find important on the back burner.”

Two weeks later, Downtown once again, the group came across the same man. He thanked them for their earlier help. “And then we said, ‘We also noticed this wound on your leg. Can we help you out with that?’” Lam recalls. The man agreed.

Lam is the president of Street Medicine at Pitt, an interprofessional, student-run group serving Pittsburgh’s unhoused population. Weekly rounds are a cornerstone of their work: Every Wednesday, accompanied by faculty from the medical school, up to 10 members go Downtown (and sometimes to Oakland) to ask people without homes what they need—and provide it whenever they can. Blood pressure checks, wound care and offers of medications, eye drops and antibiotic ointments are routine, but the clinicians on hand often provide more involved care when the need arises. If the team can’t address a request on the spot, they direct the person toward other resources or promise to follow up the next week.

Street Medicine at Pitt lets those they serve guide what the group provides rather than imposing anything. Often, even those suffering from health problems don’t ask for or accept care on the spot—they may have more pressing needs in the moment. Others have felt mistreated in formal medical settings. Many just want a sympathetic ear to listen to them without judgment.

“You are taught to be a fixer in the halls of the medical school,” says Kathleen O’Connor, a second-year medical student who is the didactic education coordinator for Street Medicine at Pitt. “You really have to let that white coat go when stepping onto the street. The reality is that for many, their chronic conditions are not a priority. They’re just trying to survive to the next step.”

Their method has deep roots in Pittsburgh: Many consider the city to be the birthplace of street medicine. It was here, in 1992, that Jim Withers (MD ’84) began donning shabby clothes and taking to the streets to provide medical care to the unhoused. The mainstream medical system had largely left these vulnerable people behind, despite their higher rates of chronic health problems. Withers put aside some of the rigid expectations of his formal training and developed a new approach inspired by the house calls he’d seen his father, a family physician, conduct. Accompanied on his rounds by Mike Sallows, who was once homeless, Withers made a point of building relationships with the people he encountered.

“We tend to have a medical focus,” says Withers, “but when you do this work, you end up addressing the whole person.” His efforts turned into Operation Safety Net, now a long-running program of the nonprofit Pittsburgh Mercy. He is also on the teaching faculty at UPMC Mercy, where each year he directs a fellow dedicated to street medicine, and is a clinical assistant professor at Pitt Med.

Withers’ model has spread far beyond his purview, inspiring new programs and organizations—many launched by his students and other acolytes—throughout the country. Here in Pittsburgh an interconnected network of groups and providers has grown over the years, aiming to provide mindful, culturally sensitive care to the unhoused population. In November, the year-round, low-barrier Second Avenue Commons shelter opened with 95 beds (plus overflow space for 30 more) and a UPMC-run health center within.

The need, meanwhile, is growing: A February 2022 census identified 880 people experiencing homelessness in Allegheny County, up from 692 the previous year. Many believe that count (conducted over the course of just one day) to be well below the actual number. Max Hurwitz, a DO assistant professor of physical medicine and rehabilitation and Street Medicine at Pitt’s assistant medical director, estimates the population to far exceed 1,000. In January 2023, the City of Pittsburgh declared homelessness a public health emergency.  

Homelessness is correlated with heightened risks of diabetes, hypertension and heart attacks. The discrepancies between housed and unhoused people are even starker for depression, substance use disorder and HIV.

Members of Street Medicine at Pitt are doing their part to help address the crisis. Among the many inspired by Withers’ work was Becky Mackenzie, now a PhD student in bioengineering and one of the cofounders of Street Medicine at Pitt. She learned about Operation Safety Net in the mid-’90s while working as an engineer in Pittsburgh. “This hit me between the eyes,” she says. “It was like, ‘Whoa, where was this guy when I needed him?’”

Above: Street Medicine at Pitt cofounder Becky Mackenzie uses her personal experience with homelessness to help guide the group’s approach. Right: Someone is happy to get shoes that fit.

Mackenzie had spent years homeless and a victim of human trafficking in Buffalo, beginning when she was a teenager in the late ’60s and early ’70s. She had hardly any encounters with medical providers, even after many experiences that left her in need of attention. Avoiding the hospital was an intentional choice to escape scrutiny or arrest, and no outreach organizations were going out to her community.

“There wasn’t even a rumor of anybody doing that,” she says. “And I know, in retrospect, there was nobody doing it.”

When she heard about Withers, Mackenzie reached out immediately—but because she had no medical training, Operation Safety Net didn’t have a place for her. She and Withers stayed in touch over the years, as she went on to become an EMT. Eventually, a spot opened for her on street rounds.

When Mackenzie later attended Pitt, she met Antonio Gumucio (MS ’19), a military veteran, EMT and a student in the School of Public Health. Gumucio had grown up in Bolivia, witnessing extreme poverty and widespread homelessness.

The two immediately clicked over a shared vision. “The kindest thing Becky ever said to me was ‘You get it,’” Gumucio says. In spring 2021, they founded Street Medicine at Pitt with med students Paul Seraly and Cameron Metz, another former EMT. Withers, a godfather to the group, serves as its distinguished honorary advisor.

From the start, Mackenzie’s experience of homelessness has been a guiding influence. But the fledgling group knew, from the hurdles past student organizations had faced (student involvement in street medicine groups had waxed and waned over the years), that the right philosophy alone couldn’t sustain it. Gumucio, the group’s first president, proposed that Street Medicine at Pitt emphasize interprofessional collaboration so their work would be constantly re-energized by enthusiasm and ideas offered from different perspectives. He established connections across Pitt’s health sciences schools; membership now includes students in occupational therapy, public health, nutrition, dental medicine and other disciplines.

“People have got a lot to give,” Mackenzie says. That has extended to faculty and institutional support. Anna Marie White (MD ’10), a clinical assistant professor of medicine and a former student of Withers, agreed to be the group’s medical director and has since been a key mentor and constant presence on rounds. The School of Public Health has provided funding, and even more has come from the Shadyside Hospital Foundation’s Cooper Fund. Anantha Shekhar, an MD, PhD, senior vice chancellor for the health sciences and John and Gertrude Petersen Dean of the School of Medicine, has been a vocal proponent of the group, which aligns with his emphasis on expanding education about inequities and social determinants of health.

The support reflects a growing appreciation in mainstream medical systems for patient-centered care, long a foundation of street medicine. “After 30 years, people don’t think I’m crazy anymore when I start babbling about this,” says Withers.

Since launching, Street Medicine at Pitt has been met with a flood of interest from more than 400 students. The organization also hosts speakers, workshops and a book club. Organizers have intentionally kept its street rounds crews small, to ensure that its interactions remain personal, organized and not overwhelming to those they’re serving.

On a Wednesday in February, Street Medicine at Pitt members trekked to the overflow shelter on Smithfield Street. The six members “rounding” were accompanied by faculty members White and Hurwitz, plus a therapy dog in training. They arrived to find about 40 unhoused people, ranging widely in age, waiting for the shelter to open at 7 p.m.

After a briefing that included safety protocol, the group began unloading supplies from two cars; then they split into two crews, one sticking by the shelter while the other walked the nearby streets. Clothes, sanitary products and food (fresh fruit, sandwiches, juice and Valentine’s Day lollipops) filled a couple of wagons—but not for long. The volunteers hadn’t even finished unloading supplies from their cars when people started approaching.

It was a mild night, much warmer than the bitter cold of the week before, but sweatpants remained in high demand. (Hypothermia is a major concern.) Victoria Lee, a biomedical master’s student, helped folks find correctly sized clothing while simultaneously fielding requests for food. Some people, expecting the group’s arrival, approached quickly with specific requests; others meandered around the crowd’s perimeter, scoping out the inventory and accepting items only when offered.

Aishwarya Mukundan, a student in the School of Public Health, was taking part for the second time. She’s been struck by the sense of community: That night, one man cut through the crowd to help carry items to people who have trouble walking. Later, the team offered feminine products to a young woman sitting with a few others. She declined, but shortly afterward, a companion returned to the wagon to grab some for her.

Amid the hectic distribution, White chatted with an man in a red beanie. Recent health emergencies landed him in the hospital not long ago; he didn’t see the point of returning, despite lingering effects. White looked up his medical records through a smartphone app. She found some good news: No evidence of pneumonia, blood clots or heart attack. White gently asked whether he’d heard of a local medical respite shelter, but he was uninterested, carrying bad experiences and little hope. He preferred to tell her about his in-progress memoir, which chronicles his time on the street. White was happy to listen.

A few weeks later, after the group collaborated with shelter staff and a physician from Second Avenue Commons, the man agreed to go to the respite facility. It wasn’t the first time someone became more open to care after connecting with Street Medicine at Pitt members on a human level. The street offers a rare opportunity to deeply listen to patients outside of the usual pressures and demands of a clinical setting.

“There’s nobody with a checklist right next to you,” says Nicole Alindogan, the group’s vice president and a first-year medical student. “The checklist probably wouldn’t even help the person that you’re talking to.”

During the group’s early rounds in 2021, Alindogan recalls, a man in Schenley Plaza often watched them from afar as they provided blood pressure checks and medication to a friend of his. A few weeks later, he sat on a bench nearby—but still declined to talk. After more than a month of seeing them around (and eventually accepting some food and a cell phone charger pack), he ended up asking for medical advice.

On rounds, White carries a small gray pack with quick access to items like gloves to address immediate medical needs; she also has a larger bag with more equipment, including a blood pressure cuff, and medications (most provided by the Birmingham Free Clinic) organized in translucent sleeves.

In light of the high rates of substance abuse on the street and the heightened risk of overdose that the prevalence of fentanyl has brought on, group members carry naloxone on rounds. They’ve begun distributing the nasal spray to anyone they encounter who will accept it—and teaching them how to use it.

The teams reconvened at the end of rounds to debrief. Each member shared a word or phrase that captured the evening: Continuity, grateful, teamwork, intuition . . . They discussed practical matters—what supplies they need to replenish, whether tweaks to safety procedures are in order. But they also allowed their imaginations to roam: How might art students get involved? (Lam has already led therapeutic art groups, among other activities, at shelters.) The following week, to address podiatric needs, the group hosted its first foot soak at a shelter.

The group also hopes to influence the curriculum to include more about street medicine. Its members and supporters believe that students are especially suited for this work.

“We have this flexibility in time, and we’re not necessarily dogmatic in our training yet,” says Kathleen O’Connor.

“So there’s creativity among an interprofessional group of students that might not exist in a traditional health care setting.”

O’Connor and her counterparts will carry what they see and learn back to formal settings, letting their experiences on the street inform care for all patients.

Some, though, find it hard to imagine heading back inside the clinic.

“Other students have said to me that street medicine has spoiled them from going back to the hospital setting,” says Lam. “And I feel like that’s what happened to me.”