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'Rough Sleepers': How one person can make a difference caring for the unhoused


The title of Tracy Kidder's latest book comes from British slang, "Rough Sleepers." It's a 19th-century term for people who sleep in rough conditions like on the street. And the book tells the real-life story of Dr. Jim O'Connell, who leads an organization called Boston Health Care for the Homeless.

JIM O'CONNELL: Most people do not like to use homeless as a noun. It's as an adjective. So it's - it describes a state. Now, the current thing that people say is people experiencing homelessness. And that's kind of the proper way to say it now. Most important is to make sure we're not stigmatizing or treating people as other than us.

PFEIFFER: For nearly 40 years, Jim O'Connell has treated men and women living under bridges and on abandoned loading docks in one of the richest cities in the country. Kidder told me that spending time with O'Connell exposed him to a world he hadn't known existed.

TRACY KIDDER: People making do with - you know, on park benches, in ATM parlors - one of Jim's patients actually managed to rent a storage locker that he lived in, if you can imagine, in the winter. There were tents on the outskirts of cities. But still what you see out there is real - really bad disease, you know, people dying way before their time.

PFEIFFER: Jim, Tracy is making me think about what you've talked about many times over the years, is that when you started in this field, you were seeing conditions like trench foot among homeless people, which you had assumed might not exist in a modern-day society. What else surprised you about the health problems that homeless people routinely deal with?

O'CONNELL: Oh, there was much that surprised me. The first thing was I was struck by how many common everyday illnesses were prevalent among homeless people, but they had been neglected for years. Most people had not seen doctors or nurses for many, many years. So there were the common illnesses. But then I also saw what I think is attendant to homelessness, is several exotic things that I wasn't at all prepared for - scurvy, for example. I remember seeing that and people with infestations, with lice and scabies, wounds that had maggots on them - all these things that I had seen pictures of in textbooks but never really had a chance to see here in a city like Boston in our - in the hospitals where I was training. So it was quite - you know, I was quite taken in.

PFEIFFER: What's your current thinking on how important finding housing for homeless people should be versus addressing their other, deeper problems?

O'CONNELL: Housing is the absolutely critical and necessary part of solving this homelessness problem. So for - from our perspective, when housing first became part of the realm, it meant that all the people that we've been seeing on the streets for 20 years, 25 years, all of a sudden went to the top of the list. You know, instead of having to get on medication, get sober, do all that to be able to qualify for housing, they became the top of the list. And they went into housing, and it was like a miracle. And we were able to - you know, if we'd been caring for them on the streets, we were able to now do home visits to them, take care of them in their homes. And it was - we were just ecstatic.

What we learned over time, though, was for the group of people that are chronically homeless, living out in the shelters and on the streets for a long time, they bear a huge burden of co-occurring medical and psychiatric and substance-use disorders. And those don't just go away when they get into housing. However, we've learned that you really have to provide a lot of support to people, and Housing First is supportive housing. So it's housing plus a support. And I think for most of us, the struggle has been how do you fund that support? How do you make sure there is enough, you know, medical and social and other supports to keep people in their housing?

PFEIFFER: Tracy, a common thread you found in your reporting about many people living on the streets is they had been through horrific trauma, often in childhood, abuse so sickening that I'm reluctant to even describe some of it out loud. And that does permanent damage. How big a factor would you say that is in your view of why people sometimes end up homeless?

KIDDER: Well, I think it's a pretty big factor. One of the psychiatrists on Jim's street team, who's now retired, once told me that he figured that about 90% of his patients suffered from mental illness or substance abuse or both. And he figured that something on the order of 75% had not just bad childhoods, but really traumatic ones. And I heard some stories that just are just so appalling you can scarcely believe that anyone would treat children that way. If I had - if there were one thing I could do to - you know, to try to end homelessness, it'd be try to find some way to end this horrifying fact. And we now know, of course, that that kind of abuse, that kind of trauma early on leaves - does leave its imprint on the body. I mean, it's going to make people unhealthy in various ways.

PFEIFFER: Jim, Tracy's book shows you sometimes wrestling with whether you're making a difference or at least a positive difference. How much do you think your work of almost four decades has changed the overall health of Boston's homeless population? Are you able to measure your success in your view?

O'CONNELL: That's a question, Sacha, that tortures us almost daily because, you know, when you look back - and I would say when I first started, I thought we understood homelessness. I thought it was going to be a relatively temporary emergent problem that we would fix quickly. And it has become seemingly intractable in our society. So when we look at outcomes, you know, we realize that we're dealing with a population living in a city like Boston, with all of our wonderful hospitals and community health centers. And this population has a mortality rate that looks more like a third-world country. And we've been trying hard to bend that curve. And I think we've been able to do a little bit, but when I step back, probably not much if you hold us to that standard. We sure are not capable as doctors and nurses to end homelessness. We can do our part to advocate for it, but we're just taking care of people while we're all trying to figure out how to solve this bigger problem.

PFEIFFER: Tracy Kidder's latest book, "Rough Sleepers," is about Dr. Jim O'Connell, who heads Boston Health Care for the Homeless. Tracy and Jim, thank you very much.

KIDDER: Thank you, Sacha.

O'CONNELL: Sacha, thanks so much. Appreciate it.

(SOUNDBITE OF MUSIC) Transcript provided by NPR, Copyright NPR.

Sacha Pfeiffer is a correspondent for NPR's Investigations team and an occasional guest host for some of NPR's national shows.

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