Treating the wound beneath homeless - When Love Becomes Health Care with Brett Feldman

Transcript auto-generated from the episode audio; formatting has been cleaned up, but wording is verbatim.

I'm Cynthia Maks and I head up the Holistic Psychoanalysis Foundation, established by my late husband, Doctor Bernard Bail. Welcome to And Now Love. Brett Feldman is the director and co-founder of USC Street Medicine, which he helped create and is an associate professor of family medicine. Bret is the outgoing vice chair of the Street Medicine Institute, and has practiced street medicine since 2007. In Mr. Feldman's role with USC and the Street Medicine Institute, he participated in the establishment of expansion of over 150 street medicine programs internationally.

He has led advocacy efforts to integrate street medicine into mainstream health care, while keeping its values and philosophy intact. In fact, a PBS documentary featuring Bret and the Street Medicine program, which he founded close to Home Street Medicine, won an Emmy Award in 2018. Welcome. Thank you very much for having me. You've got a lot going on. It was really so invigorating to find out about all the things you do now and what you did to get to this place, and all of your efforts around street medicine and helping so many people that are so needy.

Thank you very, very much. First of all, what is street medicine? Street medicine recognizes that people experiencing especially unsheltered homelessness can't access health care the way the rest of us do, for many reasons that we can get into, but it also recognizes that to actually make an impact and solve the homeless crisis, we have to address all the forms of poverty that afflict them. So of course, there's the material poverty for want of a home or want of food. And we know in LA, for example, that about 30% of the population eat for less meals a week.

There's the poverty of health, physical comorbidity, psychiatric diseases and substance use disorders. If not treated now, while they're still on the street, will prevent them from ever walking over the threshold into housing or being able to keep the housing. But as as terrible as those poverty are, it's the spiritual poverty that's the worst. The feeling unwanted or unloved, a poverty that is deepened every time a neighbor calls to have another neighbors encampment moved or swept, pushing them around the city that they feel as their home, but no place to put their physical body like, what do I do with this if it can't be anywhere?

And so we go to them on the streets, under the bridges and the woods, or wherever they are, to deliver first to tender love. And then they seem quality of care on the street that you would expect in a clinic. So the first thing you have to do then is kind of pierce that wall that's there, because they're protecting their spirit, whatever they may have left, that they're protecting some desire to to be whole. And they're used to that feeling of wholeness being chipped away at as they are moved around the city, as they watch their neighbor struggle or lose their life.

So is it that a certain amount of trust has to be instilled first, and that's your first step before you can even offer any health care? Yeah, it's, they definitely have to trust us, but we have to trust them too. And I think that's the, the reciprocal of that is where a lot of times is missing. And especially in a place like LA where there is so much outreach and there's like it's well documented trauma with the health care system and why they don't want to come into health care in LA where there's outreach, there's also trauma around outreach, people that have come and promised things but never delivered.

And so I imagine it like you're in this big shipwreck and everyone around you dies, but you're like, holding on for dear life on this piece of lumber. And somebody comes to you and says, swim to me, I'll save you. And you have to decide, do I let go of this lumber, which might be their encampment, their tent, you know, their stuff, and swim to them, knowing that other people have done that and have drowned in the process. And they make this decision. And so they have to trust us enough to let go of what they have here on the street and swim to us.

That's big deal. It really reminds me of what we talk about here, in terms of what's going on inside of ourselves and trying to get to the truth of who we really are. That sort of honest connection with your authenticity and your description is great. It's like you're out there. You've you're the only one left. You're holding on to this thing which isn't very healthy. It's not very helpful. It's scary. But if I let go. What do I get? Is am I worse off? Does it do? Is it just a void? Do I have faith? Do I take that leap? That's. That's hard. And these people that you're helping who have, you know, just been faced with this in a tangible way?

Day after day after day, I mean, the strength that it takes to commit to something that you really don't understand or you can't see what the results are going to be, that's that's admirable that they can even take the steps. And you say to that you have to have some amount of trust in them. So for example, how would that present itself? What what does someone you're helping do to help you gain trust? I mean, I don't I start with the idea that I do trust them. And even if honestly, even if they do something that, you know, makes it seem like I question it, usually there's a reason.

Usually, maybe they're afraid to tell me what substances they're using because in the past when they've done that, they've been discriminated against or weren't offered help. Maybe they'll tell me they haven't eaten that day when they have, because they usually they usually only eat like four days a week and they are going to save it for tomorrow because they don't know what's coming next. And so a lot of the mistrust is a scarcity mindset or a response to previous trauma. And so our job is not to judge that, but to kind of cut through it and pair away at some of these layers of trauma and then give them a way out, a way to feel comfortable in what's happening and to know that there's a different path they can take.

So do you start a conversation where, you know, they can see maybe not too far in that there's not the judgment there that they are sort of expecting or have known. I mean, you're looking in their eyes and hearing enough to ask questions that they might now not be as afraid to answer as they might have been three days ago. Once they, you know, sort of see that you're real with them. Yeah, that's that's part of it. And, and some of it is just letting them know that there's an understanding that we know what they're going through. So, for example, if I get when I do outreach, we, we don't work out of a mobile unit.

It's it's like a pickup truck in backpacks. And we go out on foot and we just go kind of 10 to 10 or, you know, you're driving around LA, there's somebody on the side of the road. We stop and talk to them. And if I would get out and say, hey, it's Brett from USC Street Medicine. Does anybody have any medical needs? Nobody has any medical needs. But if I first offer water and food and as we're talking just as people, then I'm constantly surveying what's happening around and observing. And there's something that I can observe that will open up more of a conversation.

Maybe it's like certain things they're collecting. Like, I have one guy he loves to collect toys. I think it reminds him of better times as a child. And so we bonded over some of the toys that he had over some of the even some of the food that they're keeping. I always find some way to connect with them. And then there's things that are may appear symbolic, but I think are more meaningful than that, that we do. So for example, when we always try and get I always bend down, try and get below, I level to give them the vantage point of authority so that they can feel more in control because they are in control.

It's their healthcare. We shed all of our titles on the street, so nobody goes by doctor Whatever, or even when we bring out elected officials and their council member, whatever, senator, whatever, before they go out. I say we don't have titles on the street. It's just people with others. And I can introduce them as this is so-and-so, who's also a council member. And so it's little things like that that I think make them feel more comfortable. And knowing that these things are helpful and are easing kind of the tension of the person you're speaking with, did you just sort of come by them over time?

There's not really a course you take because this is an evolving, horrible issue. Yeah, that's a good question. I would say some of it is learned, you see what works, but also you just treat them how you would want. It just comes to you naturally. If you're paying attention to what a relationship can be. Yeah, I think that's exactly right. It's the relationship that you're trying to build and what that looks like. And there's different types of relationships. And in medicine especially, we tend towards a like parental or authoritarian relationship where it's like, I'm the doctor, I know all the clinical guidelines and you, you're not following them.

And so we can't work together. And that's usually how we'll approach it. And I would imagine that most of us have that stereotype in mind when you're approaching all of a sudden, me, the person that could really use your help. It's going to be defensive. You know, I can't tell him that all I eat three days a week is potato chips. You know, he's going to get mad at me, you know, whatever it might be. So I see that we all want to be protective. And. And there is then perhaps a wall. Maybe it's a thin wall that separates some of us from those people that we want to help.

And as a doctor, and I think in psychotherapy that you people who are who are practicing learn how to keep a distance, but in the work that you're doing, wouldn't that distance be felt pretty clearly by the person you're trying to help and put them a little bit more on guard? And if that's the case. How do you interact with out beginning to carry all of the weight that that person is sharing with you? Yeah. Oh, I thought of one more thing. We do. So and then I'll answer the question. This is how I dress on the street so we don't dress. I don't wear a white coat, I don't wear scrubs.

And so it's just another way of connecting with them. Yeah. But to answer your question. And by the way, you look like you're in to help. I mean, you have this presence. So I get what you're saying, and you look approachable. You don't look like that doctor. That's he's going to talk to me about my potato chips. Yeah, but to answer your question, I think you're asking, like, how do we protect ourselves at the same time that we're witnessing all these things? I mean, when you go out onto the street, you see things that you can't unsee, and when you see those things, you become a witness.

And as a witness, you have a duty to come back to people who haven't been on the street. Or maybe they've driven by, but they don't really know anybody and certainly have not, like, walked the journey with them. So you have a duty to witness that to the people. And so how do you survive? This is now my 20th year of doing this. And in in medicine especially, but in lots of fields you're taught, you know, no hugging your patients, no crying with your patients. Don't get too close. It's going to cloud your clinical judgment. You'll take it home with you and you're going to burn out and you're never going to survive.

And then what happens is you go. For us, it's very obvious on the street because we see suffering every day. But it's not just on the street. It's in every hospital, in every ward, in every room. Somebody is scared and suffering. And when you meet them, you have a choice. Do you engage with them and maybe expose yourself to the suffering and some secondary trauma, or do you retreat at an act of self-preservation? And if you've been trained that the professional thing to do is retreat, then you'll choose to retreat every time. But when you do, you leave the person isolated, and you've also isolated yourself with the knowledge of knowing you've abandoned the people you've dedicated your life to serving.

And when you do that 10 or 15 times a day for years, it takes a major toll on you. And it's the exact opposite of what you've been trying to accomplish. And this is what we're seeing. It's not burnout. I hear so much about physician burnout. There's some burnout, but most of it is moral injury from that abandonment. And do you feel like there's more open discussion about this idea of moral injury now than there has been in the past? I am hearing about it all the time. Oh, that's. Good all the time. In fact, we're interviewing Doctor Rice in an upcoming podcast.

And and that is how he helps people get to what love is. Expose yourself first, you know, be brave enough to share who you really are and the person opposite you will likely then go, I can say these things about me now, and I hope that this is kind of a shift. I mean, I know there's a lot of work to do because it is really hard to hear about some of the trauma that we can't even imagine on our own, and to have that become part of who you are. But how do we honestly, authentically help each other without kind of going there? Yeah, I agree. I mean, the level of suffering on the street, you can't relieve any of it if you're not willing to get into it with them.

It's too much to think you can relieve from a distance. And so we have to be willing to share in some of that suffering with them. And if we can share it, we can relieve it. It's an interesting area to kind of study because you, you, I think, have a microscope on this process of, you know, a relationship and what it takes to have a full relationship because you're talking to people who desperately need help and are desperately afraid to ask for help. And you've got to take a step outside of the norm, let's say, or what what we've been taught to do in order to make that happen.

You can't even make headway. Yeah, well, thank you for that. Is that part of what USC Street Medicine is trying to promote in that kind of stepping over and really getting into the heart and soul of an issue? Yeah, that's fundamentally exactly what what we're trying to do because it like street medicine, as long as I've been doing it has been this radical fringe movement. And, and when I started, even the people that cared for people experiencing homelessness, but in a brick and mortar clinic said this was irresponsible. It's dangerous. You can't possibly begin like things will happen to you when you go out there, and you can't possibly begin to provide the same care on the street that you can in a clinic.

And things are shifting, and we couldn't even get reimbursed for the care we were delivering. Because when you bill, you bill for what you're doing and where, and there was no where of the street, and we had to decide, do we the where is a place of service code from the federal government. And we were deciding and within the street medicine like the the national leadership, we had the conversation. Do we try and get this place of service code that would allow us to bill and grow our teams? Would this, like, completely destroy the mission and it would get swallowed up by the system, and we made the decision.

If we would have any hope of meeting the need we had to grow our teams. And so we we went for it and we made the decision to go for it, but promised each other that our duty would be to keep the values and philosophy intact. And so we have. So do you mean then that you wouldn't want because you're being funded, you wouldn't want to be imposed with new rules and instructions that went against the grain of what you were being successful at doing. New rules and instructions. Exactly, but also temptations of, you know, different values where you're tempted to do something for monetary reasons rather than the right reason for the people like we had always done.

And so we knew if we were going to bill and others would bill, we would have to like a lot of our work, is training others how to do this the way that it's always done. And so that's yeah. So we have a workforce development and education arm in order to do that. And are you completely funded by the government? No. The the clinical team that deliver street medicine, we we build medical. Now we were successful in that. That's fantastic. And we work with the city of LA. But all of the other the like workforce development and education. We have a policy and advocacy arm which houses our state association.

That's all grant funded. And then, you know, people will contract with us to train their teams. And your association with USC means what. Everything is under that umbrella is under USC. And does USC then also fund. They support us with like HR and you know IT support. And we're in their electronic medical record. So when we we document on our patients a lot of people are surprised by that, that they have a chart within the USC system. Their chart looks exactly the same as others we do. HIPAA release consent to treat. You would never know that the visit was under a bridge and not in a brick and mortar clinic.

So you can pull up that patients information just as much as you can. The patient who's living in a house in a town. Yeah, it's completely integrated with the system. That is fantastic. So then in the course of a day, you can share information with other members of your team about a particular individual who's struggling and what a great watch system. Then. I mean, imagine it would work as well there as it does in private practice. And yeah, completely. So what is ultimately the goal of your street medicine program? There's different goals from a medical standpoint.

We want to provide the same or better care on the street that you'd expect in a brick and mortar clinic, but the ultimate goal is to help people understand how precious they are and how much they're loved by society. And we just do that through medicine. If we did something else, if I was a barber or a teacher or something, I would just do it through that. So it's the same, you know, and I've noticed that everywhere, it's like the same precious cargo of love just delivered in a different way. That's a great way of putting it. I think if we all put that first in our endeavors in life, we well, we wouldn't have the issues we have now on the planet.

But yeah, I mean, to think your barber, but the first thing you're going to do is connect with the person you're helping, whatever that help is, you know, from a honest, loving place. And that gives all of us a chance to feel really safe and open up. Yeah, that's why everybody can do this work is because we all have different talents. And if you just share whatever that is with them, you know, then it would be better. I think that's what we're missing is that sort of personal responsibility for our community, for society. It's so easy. And it's highlighted a lot in LA because we do have so many homeless services.

Is that people? They they blame somebody else for the homeless crisis. They will first they'll blame the person because they need to fix whatever position they're in. And then you blame the homeless. They call it the homeless industrial complex now because they haven't fixed it enough. And then you blame the politicians because they said they were going to fix it and they didn't. But what about what about us? Like what have we done, personally done to fix our community? There has to be something bigger than just ourselves. And and it has to go beyond the walls of your own home to you live in this community.

So if I were to say like, how do we fix how do we solve this? We need to take more of a personal responsibility, each of us for the people outside of our walls. And then you have to separate the person from their housing status to like, hate, homelessness. Everybody hates homelessness. I hate homelessness, but to love the person even more and too often we confuse it. We get mad at the person who's experiencing homelessness as if they're the same thing. Yes, I think so. I was I was watching a video recently. And the issue had to do with animals being used to test drugs like fentanyl.

Somebody sent me an article about that. Yeah. And which is I guess that's happening, but I it I mean, another terrible, devastating issue to deal with. But the answer was sort of, well, this is not okay. We need to get rid of everybody on Skid Row. This is just not okay. And for some of us listening to that, we might say, yes, that's great. That's just get rid of them. And I don't care how. I don't know what I don't know what you're going to do, but I'm going to feel so much better if I don't have to carry this in my being. And it's so easy to think that way.

And and to make somebody else, as you say, responsible. But it can't happen. We're never going to make any improvement if we can't find in our hearts the compassion to help other people like us. We're all human. Yeah. And even if you don't have compassion, if we just begin with that and you just want to get rid of the people and get rid of the problem, sweeping them, taking up like that, it just doesn't work. No. And I mean, where are they going? Exactly. It just it's just not an effective thing. And in a way, when you sweep people, this is what I've noticed, following people, because our motto is to go to the people and then go where they go.

So whether that's if they're being pushed around the city, in the county, or we get them into housing, we follow them around town and then we follow them into housing. And what happens when we move people around is that you are actually working in favor of homelessness against resolving the homeless crisis, because and so you're you're undermining your own efforts by doing that. Because when you push people around, they get, you know, disconnected from our medical care. They get disconnected from the housing people working with them. They lose their documents.

We just housed somebody. We actually have pretty good housing numbers. But I had to get them five IDs before we got one at the time that their housing came through, because they kept getting swept. Things kept getting thrown away, medications get thrown away, IDs get thrown away. And so it undermines the housing effort. Yeah. Five IDs. Five times. So. And then what happens to the people, to the person I'm going to imagine in LA, we know the average person either moves or is moved four times a month. That's like once a week. Four times a month.

So if you had to move four times a month, when would you complete all of this paperwork? They're going to send you around town to do. And and how dehumanizing though. Yeah, every step of the way, you know, to never, ever have a sense of security ever. And it also erodes trust in the municipality systems and the government systems because people they don't know this. Oh, this was the city, not the county or this was the county, not the city. And they don't know that was this branch of the government and this was this department. And so if the county comes by and it's their medical team and they say, we're here to help you, and then the county comes by or city comes by and sweeps all their stuff, which government do they believe?

The one that's moving them around or the one that's trying to help them? And the answer is they'll believe the one that most impacts their life, which means our help has to be really strong to overcome the damage that's being done. And it just hasn't been that strong. And so it's it's undermining the effort. So in your in your work, you're following the people you're helping. How how do you even stay on top of that. How do you know where they're going. How do you find them? Again it's hard and it's getting harder. There's different things that we do, especially because we're experienced in the work to find out where they're going.

So a number. So for example, one, we are very embedded in the community. And and because we've been there, we know all the spots that they might be. So usually if it's one person there's, you know, four other spots that we may have seen them before and they're likely to go to those spots. So tell us about the community that you are speaking of. Is that here Skid Row. We actually don't have a team on Skid Row because other teams cover Skid Row where we serve as it's within the city, not in the county, and it's Hollywood, downtown and South LA, and everything east is is where we go.

And how many teams. We have five teams. We're hiring for our sixth. Each team has somebody who can prescribe. So either a doctor or nurse practitioner, if you don't have somebody who can prescribe, you're still relying on referrals to the brick and mortar clinic where they can't go. We have nurses and community health workers who are people with lived experience, and they act as our street guides. They're the ones that, you know, in street medicine, you need somebody who knows the medicine and you need somebody who knows the street. And so they're the most important person on the team.

And then there's others where there's not quite enough for everybody to have their own. Like we have a psychiatrist, HIV specialist, licensed clinical social workers, other care managers. So you bring those people to a team as needed. And how do you see yourself as being effective? How do you see that what you're doing is working? Well, first, we don't in order to be effective, we can't think big things immediately in LA at any given time. There's 50,000 people who are experiencing unsheltered homelessness. We don't come anywhere close to seeing that.

So we start with one, and we do the very best we can with one and then another one and another one. And you hope over time that that adds up to something. And so sometimes success looks like people imagine it that we have because we do a lot of treatment for substance use disorders and mental health disorders. And maybe they've stopped using substances. And, you know, they're able to go through life and function even with their mental health disorder. And now they're in housing other people. It looks different that they've died knowing that somebody loved and cared about them.

And what's that like? That must be art breaking when you, you know, come across someone who's so unhealthy that they're not going to make it. Yeah. Sometimes we know and. Yeah, there's a there's a company aspect to it and a solidarity aspect to it. But I'll give you an example of what that looks like. So a few I'll never forget this. A few years ago we were working with the VA on their street medicine program, and they were putting up pallet tent shelters on the on the VA campus. And I went to visit them, and they were so upset because one of the one of the veterans they were taking care of had died the day before from alcohol intoxication, and they felt like they were such a failure from a duty standpoint.

As medical professionals, they were trying to treat his alcohol use disorder, and he died of it like tremendous failure. He had qualified for housing, and they didn't get him in quick enough because it wasn't ready. There was it's a long process. And they even had a message on their phone where he was like, F you, you promise me housing? I'm still out here, you know, and had a terrible things to say. And so from like a justice standpoint, it was a grave injustice. But as after that message at the very end, he said, okay, I love you. Bye. Oh. And when he died and they looked at his records, he had listed the occupational therapist as his next of kin.

And what a blessing it was for him to have listed somebody that, you know, on their emergency contact. They believe there's somebody that would care if something happened to them. That is such a sad story, but so clearly points to the goodness of good. Yeah. So it depends, you know, from like a duty and justice standpoint, horrible. From a love standpoint that was a success in the end. Well, Los Angeles is the community that has the largest unhoused population in the United States. And, you know, there's all these different efforts about made toward getting people off the streets.

And there are so many fabulous nonprofits and different organizations that are working so hard, tirelessly, you know, every day. And I feel like the image of those agencies, and I don't think we, the general public, even know enough about those agencies. It's like this undercurrent is generally negative, like there's a focus on what is being done that's being done wrong, or we're waiting for them to do something wrong, waiting to say, see, that doesn't work. See, you'll never have enough housing. What happened to all the money we gave you? What are you doing?

You know why are there still homeless people? And I think it's part of what you're saying. It's the challenge we all face of coming to terms with our communities inside ourselves, and the idea of helping one person at a time, one person at a time. I mean, how what a great way to start. Speaking of that, how many people do you think you helped through the course of a day. For one, one day, I'll typically see between 10 and 15 people a day. That's a lot, isn't it? Because you have to devote a good amount of time to each person and and make sure you have this wonderful, trusting relationship?

Yeah, some people see less. We we tend to we have productivity goals just like other people do. But it's not because we want to bill so much. It's because there's a lot of people on the street. And if we're not being efficient and there are ways to be efficient without sacrificing care, that it means we're not helping as many people as we can help. And so that's our that's how we define efficiency is helping the most number of people not maximizing billing like another like happens other times. So some people might see six a day. And sometimes things happen and you don't get to everybody because something happened.

And given the vastness of the issue, is there some. If you look at the issue as it is now in terms of the population that needs to be served? How many teams of people should we ideally have asked there? Oh my gosh. So if you were to this is how I calculate it. So if you. A provider has a patient panel, so the number of people they can see a year. If in street medicine a typical provider can see maybe 350 people a year, and there's 50,000 people on on a point in time count. We can't use that number because that's the number. Homeless in one night, unsheltered in one night.

The 350 is over the course of a year. So if you look at the annualized point in time count, it's about 120,000, which means we need about 300 providers. And there's about 35. Oh my gosh. And so that means we're seeing about 10% of the population. And then to check that number, what we did, because so much of our data on people experiencing homelessness is system centric, meaning we wait for them to come to us. Then we ask them things and then we make assumptions. But instead we wanted to know of the total denominator, how many people are connected to care.

And so we we went to the street, we went to every council district in the city and asked people on the street. Do you have a primary care doctor or primary care provider? And it was 7%, which is pretty close to 10%. Yes. So I think it's accurate number. And how do you promote what you're doing? Or how do people who are interested in helping find you or sort of like minded agencies? We could be better at that. We like we don't have a social media presence. Let's get you one. Yeah. But we, you know, our our the people we serve are on the street and less than 5% have a reliable phone.

And so our promotion is geared towards them. That's that's our audience. We hope others, you know, pick up on it. And that's why you know, this opportunity today maybe somebody will see it and they'll want to help. I hope so. So given that you're associated with USC, are there courses that individuals can take to help them understand what it is they can do with street medicine? There's not a course in the university per se, but we have a workforce development and education arm. And through that arm, we train anybody who would like to be trained on how to do street medicine.

And a medical degree is not required for everyone. It's required for the person who's prescribing or a psychiatrist. Right. So Corinne, who's the director of our workforce development and education, always, she always has a team that trains together, stays together. And so like a from a didactic and pedagogical standpoint, it's brilliant how she's designed the trainings where the community health worker who has a ton of lived experience but academically maybe doesn't have a high school degree, is training alongside the physicians and the way that it's designed.

They can all train together and all benefit from the same training. And those are free because we've been able to get grants in order to provide those trainings. So we work with California Department of Public Health and the Centene Foundation to provide those trainings and other trainings. What is the Centene Foundation? It's a managed care organization. The managed care organizations in this area. I know people have different issues with them. They've also been very supportive of the work. And because like I said, street medicine was really new to the system.

It didn't it doesn't really fit in managed care, but the people on the street are their members. And so they've had to be very creative, and they've been willing to be creative in order to figure out how to. The question, what can't be? How do we bend and mold street medicine, which we know works to fit a system which doesn't work? But how do we bend and mold the system to fit street medicine? Yeah, and they've been pretty like accommodating. Obviously we're not there yet, but we've made progress. That's great. I mean, just that the there's insight there that is fantastic because we all like things to bend our way.

So when you started you started in Pennsylvania with this. How did you get started? Well, how I got started just in with people experiencing homelessness is when Karen, my wife, when she was a student in Chicago and there was a shelter based clinic and I was not a student, I was an outsider, but I, I noticed that when her classmates, they loved going to the clinic, it was the waitlist was way longer than they could accommodate. But then when they went out on clinicals and they started seeing other patients, they came back so different. It was like cool to be jaded, you know, health care be so great.

If it wasn't for those patients who don't do this and don't do that. But then when they went to the clinic, it's like somebody hit this reset button and they remembered why they wanted to go into medicine. And then when I moved back to Pennsylvania for for me to go to school, it was a selfish thing. I didn't want that to happen to me without the protection of a clinic. And so we looked into who was caring for people experiencing homelessness in the Lehigh Valley, Allentown, Bethlehem and Easton. And there was nothing. And so we started at this at the Allentown Rescue Mission.

And as time went by, I was still a student at the time. Then I graduated and volunteer. There was all volunteer. We noticed that we were tied to this clinic and tied to the shelter, and when people would leave, we wouldn't know what happened to them. So you could only provide services if someone came through the door? Yeah. And then there's always the one patient that changes your mind on how things work. For us, it was a gentleman named Scott who had an intellectual disability. He was in his 40s, but intellectually he was about 8 or 9. And, oh, I'll tell you a different story about Scott first.

So he came in first day. He had an elevated blood pressure, but no diagnosis of hypertension. So we said, come back, we'll check it again. And he came back twice a week, every week for three years. And then we were sitting around. Anybody tell Scott he didn't need to come back anymore and nobody told him. So I said, well, I'll tell him until I was like, you know, you don't need to come back. You had this one high blood pressure. It's been fine since then. And he said, well, who will teach the students how to take a blood pressure? Oh my gosh. And I was like, you're right.

Just keep. Keep coming back. Well he loved the community. Loved it. And and we loved him. You know he was part of it. Then one winter, it was January. They found a pornographic magazine in his locker, which was against the rules. And they kicked him out on the street in the winter. And we were so worried he would freeze to death or starve to death that he wouldn't know how to survive. He'd never been outside before. So I went looking for him, and I found him not far from where the shelter was, under this bridge. And I remember going down under this bridge, not knowing what I would see, even anybody.

And I see him sitting by this fire with all of his friends. And I peek under and he's like, hey, Doctor Brett. He's like, so excited to see me. I he was well dressed, well-fed. They took such good care of him. And so I just I didn't know it was called street medicine. I didn't know I didn't tell my employer. I didn't tell my malpractice carrier. I didn't know I was doing anything different. But I just started seeing Scott and his friends under the bridge. And then they introduced me to their community. And later I learned what I was doing, had a name and the the Street Medicine Institute, which I'm a part of now.

I connected with them. They taught me how to do it better. And that's that's how it started. That is such a great story. So when you were meeting with Scott and his friends, you were really just there to help them with their health issues. You weren't there to say, I'm going to get you off the street so much. Or were you? I mean. I'll be honest, in those days there's just no housing. So we would be lucky if we housed 1 or 2 people a year. So it really wasn't on our radar because it wasn't a possibility. So you were really giving them the best, helping them have the best tools they could to live in these extraordinary circumstances.

Yeah. And if they were healthier, maybe they would feel well enough to get a job or do something to resolve their own homelessness. And you hoped that day would come. The International Street Medicine Group had then been in existence before you discovered street medicine. And how does that operate? Is it basically what you're doing? But across cities around the world? Yeah, it's I'm the vice chair now, the of the International Institute. Because you have a lot of free time. Totally. But it's mostly like education and and technical assistance consulting.

It doesn't provide any direct patient care. It's like to train and equip others to do the care. I see. So sort of set up a package. This is how it works. And then that gets out to different communities in the world and kind of back again to Los Angeles, because this is there's such a focus on our homeless issue. And it's frustrating for everyone because wherever your heart is, you don't want it to exist. Of course. But you know, I again, I keep hearing these sort of proud statements of, we're in Venice and we're, you know, sweeping the streets clean, and we're going to put all our efforts here.

But where is everyone going after they it's not possible for them all to go in shelters. Is this a case of them being shifted, you know, three miles away? It is the. Work to move these people someplace else, considered on an individual basis. Does the group removing these people look at one person and say, have you got family? Can we help you get back to your family if somebody is severely ill? Are they able to help them with their personal issues or is it just a sweep? Yeah. You know, since we're on a show that people might listen to instead of just like a soundbite or a social media post that they just scroll through, there's nuance that's important to understand that when so they call them encampment resolutions is like the umbrella term.

And there's different kinds. And so you have to understand some of the nuance. And it's important. So sometimes what we call as a sweep is exactly kind of what you're describing. We don't care where you go. It's just not here. And they just throw everything out and see you later. And do they put you on a bus and drop you off someplace else as a group? Usually? No. Just walk away. Just walk away. You just can't be on these blocks and it's usually not three miles away. It's usually just a few blocks away. And most of the time they'll come back. Unless, you know, the police are willing to patrol it.

Because they've had many of them have had a chance to develop a community. So they want to come back and be tented next to their buddy. You need every advantage you can possibly have when you live on the street. So whether it's your buddies that you're out there with, if it's like a taco stand that's willing to give you food every once in a while, a laundromat that's willing to let you sit in there, you know, that area. And a lot of them. That's the other thing. A lot of some of the perception is that everyone's coming from somewhere else to be homeless in LA because the weather is so good, but a lot of them, they grew up in that area and they're homeless in that area because that's where they grew up, and they know people that are willing to help them.

Not everybody, obviously, but that's more than I think people would think. Yeah, probably. But it does make sense. Yeah. And then other encampment resolutions, like for example, inside safe, inside safe, the mayor's initiative. I know people criticize it for the cost. And this the cost is not my expertise. But I'll tell you, when they do an inside safe operation, they're moving people to, there's a there is actually a hotel they're going to in in transitional housing. They've identified a bed. So they don't step into a community that needs help until they know they can offer the help.

Exactly. First they have to have the hotel. Then they identify the community. I mean, they have a list of people waiting, but they don't resolve it until they have a hotel. And then they get a list of people who live there and offer them the hotel. And there's a bus that comes and picks them up and drives them to the hotel. And is that then not so much a sweep, because there could be people on the street who say, I'm not going. Yes. That's right. And so it's it's that option of that and an actual place that's being offered. And the other thing is the transitional housing, those hotels they're going to.

There's not a time limit on them. In the past there had been years a hotel voucher for a week or two. They're in the hotels until they can get something permanent. And so I have people that have been there for two years in that now why they can't move out of the hotel into permanent housing. That's some that's a totally different, different problem of why is there no permanent housing. Yes. And everybody then also has a different story. Yeah. So but they are off the street. Yeah. So and I think the idea of giving someone temporary shelter a week or two is again, one of those things that might have the opposite effect.

Right. Because you've had that little bit of comfort and now you're kicked out and you're back on the street. That's right. And remember where when we first started our conversation and we talked about the the lumber. So they've swam to us. We've put them in the hotel and their lumber is gone. And now we've kicked them back out without that. So even worse. Even worse, because they used to have a tent. They used to have a community. They used to have things that were essential for their survival, that they, you know, kept outside. We asked them to throw all that away, to go inside.

And now, two weeks later, they're back out. Such a shame. So, when one I think we're a little off base because this isn't really street medicine, but when an individual goes to stay in one of these shelters and maybe they're there for a year or two years, aren't there a lot of restrictions on what can happen there? And isn't that part of why some people reject that as an idea? Yeah it is. And and actually that gets back to us trusting them. So you see an inherent mistrust of the people in some of these policies. So for example. It's like at the base.

Of it. Yes. We're going to put all these rules in place because you are not to be dressed. Yes. Yeah. So for example we want. They have to some, some you have to walk in through a metal detector and any weapons you have will be confiscated, including your fork because that could be used as a weapon. But you know best probably not. Not a very effective weapon. And it's in my home. I'm allowed to have those forks or like, you're not allowed to have visitors, but you really want them. You know, they left the community and you want them to establish a new community where they live now, or else there'll always be this pull back to the street with their old community.

But if you're not allowed to congregate, you're not allowed to have visitors. How do you establish a new community where you now live? That seems like such a big deal, really. I mean, I think part of what I'm learning from you now is that being on the street, one of the things that helps you survive is your community, whatever that is. And to think, okay, I'm going to have a bed, but none, no people, no, no comrades, no community. That's hard to shift to. Yeah. That's been like, I know right now there's a lot of criticism of housing First. And for those of listening that aren't familiar with Housing First, the original idea was that before Housing First, they talked about housing readiness, where you had to prove yourself while still on the street, that you could maintain housing and.

And what would that mean? It would mean you had to jump through all the hoops of getting ready for housing. So you had to get all your documents ready, which is extensive. Maybe you had to start treatment, you had to stop using substances, which is hard to do outside. And and then the idea of housing first was that first you would go into housing and and once you're in housing, you would be more settled and then you would have treatment begin while you were in housing. You could get your documents ready easier while you were in housing. But the reality hasn't measured up to that.

It's been largely a fantasy where one there hasn't been enough housing to really do housing first, because you're waiting six months before you get housing first or a year. And so you're doing all that stuff on the street anyway. And then we've, it's part of the actually part of our own fault of in the process of trying to. Like some of the biases against people experiencing homelessness, being driven by mental illness and substance use disorders. We've downplayed that to such an extent that we are saying housing is the only thing that they need, and so they've been moved into housing without these supports.

And that's why part of the reason you see these big returns back to the street is they haven't been supported. And why has that been downplayed? Because there's no way to financially support what's required in terms of help. I think it's a number of things that's part of it. It's expensive to want to to provide care, you know, health care, even if you did street medicine, even though it's been around for a while, it hasn't been in the public conscience and in the conscience of. You know, politicians and legislators and stuff. It's only been a few years.

And so I don't think they knew that that was like that was actually what they were missing. And then, as I said in a to like, destigmatize, we downplayed it to such an extent that people weren't getting the help that they needed because we were pretending they didn't need it. And so, yeah. So there are a lot of people on the street who, maybe three months ago, were just two steps from losing everything they had that would allow them to be housed, and something went awry. And now they are without a home. There is a group of people like that, a large group of people.

But somehow our mindset makes it easier for us to have compassion for those people than people who have drug issues or sort of mentally unstable. Is that do you see that? Yes. There's definitely a separation between the deserving poor and the undeserving poor. And so and a lot of the nonprofit sector has played into it where, you know, we need to find somebody to represent our organization. And so you're looking for the perfect person experiencing homelessness that is just down on their luck and, you know, just needed a little handout or a hand up.

And so we've ignored other people that actually need help. Well, we've worked a lot with Homeboy Industries. And it's, I saw Father Boyle on here. Yes, yes, yes. What a wonderful experience that was to learn so much from him. But, you know, they're doing what you're suggesting in that they are. Giving all of these individuals who have had a tough time in life, a tough time, you know, whether it's drugs or they've been jailed for something as serious as murder, and they're bringing them back and looking at them, you know, eye to eye without judgment and calling them people and human and equal to the rest of us.

And, you know, they're they're not so much being given a leg up as being given the gift of being seen for who they really are. They're not that bad thing that they once were told they did. Yeah. Recognizing their humanity, honoring their humanity. It's a form of liberation, really, because and I think we don't think about that in a lot of the work that we're doing. Enough on how to resolve homelessness, where you have somebody who's in this big, you know, this big crisis on the street, and then we've moved them into housing, and that's been the goal.

But they're not liberated in any way now. They're now they're just in four walls, but they don't have a sense of like, you know, like there's dignity and work and there's dignity and giving back to your community. And you and I want to feel useful to others in some way, and so do they. And we haven't focused on that, like after the housing. What then? That's nice that so many of these people are being respected for the experience that they had, and that there's knowledge to be had for the rest of us from that experience, and that they're on your teams because they know how to be in touch is fabulous.

Yeah. Some of some of the way that we're talking now is could be weaponized if taken the other way. Like they say, you know, you're right, Brett. They need treatment and they need for mental health disorders and substance use disorders, and they're not willing to accept it. And we must force it. And so there's the potential before we move on to the next thing that that can be weaponized. And that's where I think street medicine really shines, is that I haven't found it difficult for them to accept treatment. I've actually found it to be fairly easy.

This population got such a reputation of being difficult to engage, difficult to build that trust. It can take months to build trust. That has not been my experience. And what you'll find when you when you actually like, talk to them and listen to them. It's very uncomfortable to have a mental health disorder or a substance use disorder. And you know, like if you have say, say you're having like auditory hallucinations or visual hallucinations, these usually are not pleasant. You know, like the auditory hallucinations, you're hearing things that aren't there.

Sometimes it's like really loud noises or people talking about you and saying terrible things about you, telling you to hurt yourself. The things that you see are usually not good, right? They're like, maybe people chasing you, maybe they're demons. It's disturbing when you have a substance use disorder, your life is taken up by this substance. As soon as you wake up in the morning, like you're not easing into your day, into something different. You just have to find the substance, not to get high, but just to prevent yourself from getting sick.

Like, you know, nauseous, vomiting, diarrhea. All this stuff on the street is a terrible thing. And so when you talk to them about like about this discomfort and you are offering something to relieve that discomfort, most of them will take it. I haven't found that to be a problem. It's I think, the people that don't realize that street medicine exists or don't realize how effective it is that feel that they have to resort to this force treatment and you don't have to. And what is that on the street? When you know an individual thinks they're coming in, they're going to help this person.

They're going to force them to stop taking these drugs. How does that even work? How do you how does someone go onto the street and say you're no longer taking drugs? I mean, I don't understand how that would even. Yeah. I mean, I think they're trying to figure that out now on what that forest treatment would, would look like. Some of it looks like incarceration. Some of it looks like psychiatric holds. And sometimes a psychiatric hold is needed. I just think that most time it's not needed. And would the idea of the incarceration be that here these people are with no access to drugs.

So that's going to start the good ball rolling. Yeah. And is there some notion of how long that incarceration is to take place. But usually it's not framed in that way. It'll usually be like a charge for possession or something like that. So you are being arrested. You are being arrested. And so you have to go through the normal steps it would take to resolve whatever the issue is. Yeah. And now like one of the things we're working on now is the in in corrections. They're starting people on medication assisted treatment. Say they use fentanyl or something on the street, heroin or fentanyl.

And now they're on this medication and they have stopped. Then they get released. And there needs to be a transition on who's going to write this, who's going to write the next prescription. Otherwise they're just going to go back to using. And so we're imagining ways for us to go into these facilities and continue the medication as an outpatient or avoiding the incarceration altogether, where like it's a low level offense and, you know, they're open to treatment. Like I said, if a lot of them want actually do want treatment, and instead of being carceral, they'll get treatment from us.

And so there's there's some good things that are coming from this. So then are you working with the agency that's creating this incarceration program, let's say, to figure out how you can still help those people that are incarcerated? It would be not during their incarceration. There are other people treating them during their incarceration. Like you said. What happens? Yeah, ours would be afterwards. But all this is, say there are some like very, very different innovative ways that are being thought of right now to solve this. Well, that's good news because it is overwhelming.

It is. So what would you tell us as individuals that we can be doing to help the situation? I would say to get to know your neighbor. You know, some people might say, I hate people experiencing homelessness or I love people experiencing homelessness, but do you know them? And so if we there are many more housed people in LA than on housed. And if we all took a personal responsibility, we didn't just give it to the government, give it to the politicians, give it to the homeless service providers. It would be so much easier to solve. And is the best way to do that, to be working with an agency and organization or an organization that's providing some kind of care, or can one.

Approach people in a homeless situation and make an attempt to make a connection? I mean, that could be dangerous. It's up to the person and how comfortable they feel. And but I believe everybody can do something. So some people might feel comfortable just going outside their front door to the person that they've seen there for many, many months and offering something to eat and asking what their name is. And you can start their if you're not comfortable doing that, then maybe you can support an organization doing that. But I think there is a responsibility that we all have to care for our community.

And what kind of. Love or how are you seeing love in the relationships that you establish with these people? Well, everybody recognizes it. I found no matter how like, no matter what extent you're experiencing psychosis or no matter what is happening in your life, that when somebody comes to you with love and humility, people understand that language. It's a universal language. And you asked about safety. That's been our biggest protection. It's not having a big guy with us. It's not having a weapon with us. It's that approach of love and that will keep you safe.

I learned this lesson early in street medicine. There was two, two things that happened early in my career. One was there was this guy who lived in the woods, who was a Vietnam veteran and had like his own little encampment compound in the woods. He went to the woods in 1982. And because he just didn't, like, fit in in society. And so we started visiting him and I would take everybody back there to visit him. He was a wonderful person. And we would sit there and talk about the books he was reading and all those things. And one time we were coming out of the woods and the police were there and they told us, don't go back there.

He's dangerous, he has weapons, he has all these things. And I'm like, Jarvis. Like you were so surprised. I was so surprised. But we hadn't seen him for many, many times. And it was just because we treated him with love and respect. And he really enjoyed our visits. We really enjoyed him and it was just a different level of understanding. And then there was another guy who was so mad at we used to go to the soup kitchens. He was so mad. He was yelling and screaming, throwing trays, throwing chairs and all kinds of things within the soup kitchen.

And and I knew his name. And so I went out and he was doing his thing, and I just sat down next to him and watched him. And he was so confused why I would do that. And he starts and he was like looking at me. And I asked him if he would sit next to me. And so he did. He sat next to me and we just started talking. And after a while the world continued on and people started ignoring what was happening here. It seemed like a long time. I thought they were just watching us, but yeah, it was again, like I wasn't a threat sitting on the ground to him.

And it was confusing that somebody would react that way, which got his attention and didn't escalate it. And that's how that's how it ended. It was us on the ground. That's beautiful story. You can almost imagine that he was acting out in that way as a form of self-protection. Don't get close to me because I can't trust you. I can't trust you. If I let you in, you're going to hurt me. So I'm just going to make sure constantly that all of you stay away. And here you were saying no, not so much. I'm here. I think that one thing we can all try to do is undo our assumptions.

I mean, generally in life we should probably be doing that. Well, again, how do we support you or how do we find you? I think you're doing unbelievable things and we need more of it. So we we need to promote you, fund you, help you. We have a website, USC Street Medicine has a website, and we take donations, whether it's money or we always need like food to give out to people. Because like I said, food is difficult, water is very difficult. And sometimes you just start with that. Yeah. Those are so important because those are our tools of engagement that opens the door for us.

And so sometimes we'll get organizations that want to make bags to give out with food and socks and those types of things in it. And we always love those things. So even individuals in a community could come together and create a lunch bag and somehow get hundreds of those off to you, and you could distribute them. Yeah, we would love that. We see lots of people and we run out quick because people are starving on the street. But on our website, my my email is very public. So they can email me. Okay, okay. Well thank you. Thank you so much for being such a loving human.

And we need more people to come from this loving place. And in our conversation, I've said several times seeing eye to eye, but you are so unique because I feel like you are really looking at me and I appreciate that. So I see that you're doing this with everyone that you speak with, so it's coming from your heart. Thank you. Thank you for spreading love in the world. Oh, thank you, thank you. And now love. I've never heard a podcast called that. It's a perfect name. Yeah, well, we do mean it. And now it's kind of imperative. Yeah. We're sort of falling apart.

And I think the only way to undo that is to figure out how to love each other. That's right. Thank you. Thank you. Please follow, rate and share this podcast and pass it along to someone who might need it. This is a now love. Listen to your dreams and live from your heart. Thank you.