Last July, I visited Pittsburgh Mercy’s Operation Safety Net, the street medicine program founded by Dr. Jim Withers. In the 1990s, Dr. Withers began slipping out of the hospital in the middle of the night to provide medical care to people sleeping outside — on sidewalks, in encampments, under overpasses. What began as one doctor’s scrappy practice spread to more than 150 programs across the country.
Street medicine embodies what health care should be: tending to those who need it most. It is also a stark indictment of our society that such care is as in demand as it is. Unsheltered homelessness is near a record high in the United States, and people living outside are sicker and more likely to die — at 10 times the rate of those who are housed and three times the rate of those who are in shelters, in one study. This winter, in New York City, around 20 people froze to death outside, many of them likely homeless, during a three-week cold snap.
Cities across the country are fighting over how to respond to street homelessness — now a national political flashpoint, with the Trump administration forcing the homeless into institutional settings, out of the public eye. What is clear from all these places is that some people living outside are never going to seek care at a hospital, clinic or shelter, no matter how much they need it. Many people have untreated psychiatric conditions that make attending scheduled appointments all but impossible; others can’t risk leaving their life’s belongings unguarded. Past medical encounters may have left them feeling alienated, scarred. “It’s only if you get out in the street you see what’s going on,” Dr. Withers told me. “And then you begin seeing the ineffectiveness of the system.”
More of us in medicine should be asking not only how to care for patients once they come through our doors, but how to reach those who never will.
One morning in Pittsburgh, an outreach worker called the Operation Safety Net team, worried about a middle-aged man they knew as Tyree, who had insulin-dependent diabetes. Tyree’s main concern, though, was getting methadone to soothe his opioid withdrawal symptoms.
Tyree’s methadone clinic, located across town, would require several bus transfers and a long walk to get there. This was hard for Tyree, who uses a cane. He is entitled to Medicaid-funded cabs, but they must be scheduled ahead of time — a challenge when he can’t stay in one place. Drivers also won’t wait or help him into the car. So they usually leave without him.
Dr. Withers and a nurse, Maisie Taibbi, found Tyree outside and took him in their van to his methadone program. Ms. Taibbi cleaned and dressed some infected wounds he had acquired. Dr. Withers gave him antibiotics. Though they had spent more than an hour with Tyree already, the team bought him a hot meal at a nearby convenience store when he asked.
Another day, I followed a nurse practitioner named Danielle Schnauber Jones as she visited an encampment under a bridge littered with needles. One man, who was injecting drugs when she showed up, complained of ear pain. She waited until he finished before examining him, then offered him ear drops. As we were leaving, the man said, “It’s scary as hell right now.” The city was sweeping encampments like his.
A medical team can do a lot on the street. They can draw bloodwork and manage chronic conditions, screen for cervical cancer with self-swabs and tend to complex wounds.
Hospitals can also bring in a provider from Operation Safety Net to help. This is useful because these patients may trust the team but not the hospital staff. When a team member comes to the bedside, patients may feel comfortable enough to stay. The team can also devise what Dr. Withers calls “a reality-based discharge plan”: Patients without reliable access to restrooms may never take diuretics, for example, so giving another medication instead. The team have managed to heal patients, even those who require complicated care, by adapting treatment to the realities of life on the streets.
Progress can be slow, uneven. It took a year before the street psychiatrist earned one woman’s trust enough that she was willing to start medication, a monthly shot. Her mental illness stabilized — long enough for her to secure housing. Then, she started to refuse the injection. But, during my visit, she still had her apartment.
“Success looks different for street medicine,” Ms. Schnauber Jones told me. It may look like a healed wound, four months off drugs, someone simply looking better. Or, she said, “I got them through this day, this winter.” Or it can be even more fundamental than that: “Their acceptance of my support is a win.”
Dr. Withers argues that street medicine should be understood as similar to the work of a fire department: part of the civic fabric, a public service as vital as any other. Until recently, though, it was treated as fringe. Some critics even called it irresponsible, questioning whether these patients, many grappling with psychiatric illness, could truly consent to care or whether treatment delivered on the streets met clinical standards. Then, in October 2023, Medicaid formally recognized care on the street, paying for it for the first time.
The advocacy behind the Medicaid change was led by Brett Feldman, a physician assistant who helped start a street medicine program at the University of Southern California in 2018. Today, Mr. Feldman runs one of the largest, most sophisticated street medicine operations in the country, caring for more than 1,500 patients a year in Los Angeles.
When institutions and governments invest in street medicine, the results can be striking. E.R. visits dropped by 80 percent for patients in the U.S.C. street medicine program; their hospital stays decreased by 2.5 days, and readmission rates fell by two-thirds. Over 80 percent of those with hepatitis C were fully cured — no small feat for a treatment regimen that requires daily medications for several months. Those in the program are also four times more likely to secure housing, with help from organizations who guide them through the process — and from the medical stability that enables them to see it through. At its best, street medicine is the envy of health systems everywhere: It reduces costs while improving outcomes.
But street medicine doctors are wary of emphasizing cost savings too much. While cutting costs may be a byproduct, “it can’t be a driver for this,” said Dr. Patrick Perri, a former student of Dr. Withers who is now the medical director of the Center for Inclusion Health at Allegheny Health Network. He pointed out that if you’re focused solely on saving costs, the easiest way to do so is to let a person die on the street.
While Medicaid’s recognition of street medicine offers a sense of legitimacy, it does not answer the harder question of how to sustain the field. As street medicine is drawn into mainstream systems, clinicians worry that it will increasingly be judged by the productivity metrics and reimbursement demands that shape the rest of health care. Formal recognition could force the field to “bend to fit the system” — something Mr. Feldman strongly warns against.
Long mornings tending to patients like Tyree would become unimaginable. “On the bean-counter sheet, that looks crazy,” Dr. Perri acknowledged, compared with the productivity of a brick-and-mortar clinic. “People would say, ‘What the hell are you doing?’”
The Trump administration’s cuts to Medicaid and food stamp benefits, along with new work-reporting requirements, threaten to make life even more unstable for the people who rely on street medicine. In the E.R., I often see patients who have been disenrolled from Medicaid for bureaucratic reasons; any added administrative hurdle will crush people living on the street, without reliable phones or addresses.
“Just the Medicaid work requirement alone will have a profound impact on all of our work and the people we serve,” said Mr. Feldman, who lobbied unsuccessfully for homelessness to be an exemption. With his program’s help, about 85 percent of his patients have enrolled in Medicaid, but he predicts that figure will drop below 10 percent next year once the new eligibility restrictions go into full effect. At the same time, cuts to food stamps and other supports will likely push still more people into homelessness, making the need for street medicine all the more dire.
Street medicine programs do not survive on Medicaid alone. They depend on support from academic hospitals, nonprofits and publicly funded health centers — institutions that are increasingly vulnerable to political and financial pressures.
Over the last three decades, Dr. Withers has seen street medicine programs shutter. Even his own has been downsized in recent years. Yet he remains undeterred. “You have to keep fighting for it,” he said. “It’s easier and easier to say people like Tyree aren’t worth the trouble.”
Every few months, in the New York City E.R. where I am a doctor, I take care of a man who lives on the streets. He has H.I.V. and a leg infection so severe that he needs surgery. Sometimes he stays long enough to get one dose of I.V. antibiotics. Sometimes he doesn’t. I can’t stay here in a place like this, he tells me.
I think I know what he means. When people who are homeless come into the E.R., they often frustrate the people working there. These patients want extra food, more blankets. They want to wander. They might smell bad, demand drugs, fight with other patients or the staff. That frustration can seep through — to the way we speak, how we act.
What these patients expose is not merely their own distress, but medicine’s inability to care for people in a health care system that is not built for them — one that is built, in many ways, to keep them out.
During my time with Operation Safety Net, I saw what kind of care becomes possible when clinicians go out to find patients. We tend to think of the E.R. as America’s safety net. But for people living on the streets, the real safety net is street medicine. Until we fix what makes that work necessary, it needs to endure.
Helen Ouyang is a physician, an associate professor at Columbia and a contributing writer for The New York Times Magazine. She is also a fellow at the Type Media Center.
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