By: John Tucker Sigalos
If a tree falls in the woods and no one hears it, does it make a sound? This classic cliché sums up the main take away that I had from the Street Medicine Conference I attended this past October. Before I explain why, let me set the stage. My name is John Tucker Sigalos, and I am an MS2 at Baylor College of Medicine (BCM), a manager at H.O.M.E.S Clinic, and a Board member for the clinic as one of the BCM representatives. When I, along with six other medical students representing both BCM and UT Houston, arrived in vibrant San Jose, we were prepared to learn from the experts how we might better serve the homeless population at our student run clinic, and to gain insight into how we could start a street outreach program that would bring healthcare to the hidden urban populations.
Over the first two days of presentations, lectures, talks, breakout sessions, and sharing of ideas, we listened to heartbreaking personal stories, heard about the services that were being provided to homeless individuals around the world, and learned about the challenges that were overcome to provide these services. An undercurrent throughout these learning opportunities was the issue of being a healthcare provider with very limited resources, due to having an antagonistic or dismissive relationship with those who control the resources. Stated bluntly, there was bubbling frustration that, “Nobody cares about homeless people and their well-being.”
This led me to two questions. How do we as students, physicians, social workers, and all others who would like to see progress made on improving the health of our poorest citizens actually make effective change, and who has the ability (power) to make change? The second question is a bit easier to answer. Our government, hospital administrations, and insurance companies make a lot of the decisions on how resources are allocated. With this group of people in mind, one might picture well-dressed men and women sitting in a boardroom making decisions about money that will drastically affect people’s lives whom they haven’t even met. This impersonal and money based approach irks the moral sensibilities of those passionate about making change and providing care to the underserved. The argument from those out there on the streets helping homeless people is that, “I cannot believe that anyone who could see these people and hear their stories could not feel a moral obligation to help them.” In order to spread awareness and inspire people to care about the problems of the homeless, there have been documentaries produced describing their plight and the deplorable acts of government in films such as Lost Angels: Skid Row Is My Home and Exodus From the Jungle. Yet, despite being interesting and thought provoking films, it is easy to see that providers, students, and activists are speaking a different language than the resource brokers.
This thought process leads me to the conclusion that in order to effectively help the homeless, those in the medical community need to hold their treatment and resource allocation to the same standard that we do everything else. Plainly, we need to do more research. Research and action through evidence based medicine is the way that healthcare providers prove we are doing the best possible job for our patients. I believe that through this method we will be able to show that helping the homeless and those in need is not only morally responsible, but fiscally responsible as well. Think about this scenario: A homeless man is on the street without access to healthcare and has uncontrolled high blood pressure. How much money will it cost to give him Lisinopril for a year? After searching online I found that the average price for a thirty day supply is roughly ten dollars. Over a year, let’s round up much higher and say it would cost two hundred dollars to supply this man with his medication. Without this medication, let’s consider the scenario in which this man has a stroke as a result of his untreated hypertension, presents to the emergency department, and must remain in the hospital for weeks. Now, how much has this man cost the hospital and the government supporting the hospital? Thousands? More than a hundred thousand? I am not an expert on hospital cost structure, but it makes sense that you could prevent similar tragic events and treat a lot people for much less just by reducing the heavy burden of acute, late stage, and preventable health care costs. Even though this thought experiment makes intuitive sense, we are not doing the high quality research necessary to prove that providing sustainable, chronic healthcare to patients without access is actually beneficial to society, including the resource brokers who make the decisions. The physicians and other people on the ground are doing great work and providing great services, but instead of doing research and documenting how we are being effective and how we can improve, we are only making documentaries.
The scenario I detail above was tackled on the last half day of the conference by Dr. Sheryl B. Fleisch, a psychiatrist at Vanderbilt. Dr. Fleisch is in the midst of generating ground breaking work that proves her way of providing mental health services to the homeless with chronic treatment is saving money for Vanderbilt’s medical center and improving lives. For her, and for those of us in the medical community who want to make sure that all those in need receive medical care, “money and cost” don’t have to be dirty words that create boundaries to care. With research and simple documentation, we can speak the language of those with decision making power and build a coalition that allows physician care to break through their current four-walled boundaries and extend into the streets and the community.
So, if a tree falls in the woods (if a caring physician helps a homeless patient in need), and no one is around to hear (and we do not do research to document our success as leverage for more opportunities to help), does it make a sound (are we really being as effective as we can be in our mission)?