Rough Sleepers: Dr. Jim O’Connell’s urgent mission to bring healing to homeless people by Tracy Kidder – Here are my five lessons and takeaways (and much more)

Rough SleepersDr. Jim—James Joseph O’Connell—had been riding on the outreach van for three decades. During those years he had built, with many friends and colleagues, a large medical organization, which he called “the Program,” short for the Boston Health Care for the Homeless Program. It now had four hundred employees and looked after about eleven thousand homeless people a year. Jim was its president, and also captain of the Street Team, a small piece of the Program, with eight members serving several hundred homeless people who shunned the city’s many shelters and lived mainly outside or in makeshift quarters. …all of his clinical work went to doctoring its patients, Boston’s “rough sleepers,” as Jim liked to call them, borrowing the British term from the nineteenth century.

When Jim had begun these tours on the van through Boston’s nighttime streets, he had imagined the world of rough sleepers as a chaos. But it turned out that most of them had territories where they hung around and panhandled during the day—“ stemming” was the street term, its etymology obscure. For sleeping, they had favorite doorways, park benches, alleys, understories of bridges, ATM parlors. …Rough sleepers were like homebodies without homes.

Jim was like a 1950s doctor making house calls, though the van rarely dispensed more than minor medicine.  

In any case, once people have fallen to living on the streets, they have reached a certain horrible equality. 

“The pull of the streets” is a phrase that Jim and his team have used to explain to themselves why many of their patients leave detoxes and hospitals before their course of treatment is finished—leave “AMA,” Against Medical Advice.  

He speaks about the difficulty and danger of applying measurable standards to the treatment of rough sleepers.

How do you treat HIV in a person who has no place to live? How do you treat diabetes in patients who can’t even find their next meals? How do you treat physical illnesses in mentally ill patients and patients whose days and nights are ruled by the consumption of alcohol, the search for narcotics? …He was discovering the role of homelessness doctor, with a lot of help from Barbara McInnis. 

Tracy Kidder, Rough Sleepers: Dr. Jim O’Connell’s urgent mission to bring healing to homeless people


“You are what you think about all day long.” 

I used to say that this quote came from Aristotle.  A sharp participant in our gatherings said that he could not find the source.  It turns out that it is one of those sayings/quotes best identified with “source unknown.”

But, it is true, isn’t it?” —  “we are what we think about all day long.”

I have read a lot of books in my lifetime.  And these books have shaped who I am.  What I think; what I believe; what I am concerned about; what I think about all day long… So much of what I think about, and care about, comes from what I read.

In my professional life, I present synopses of two very different kinds of books every month.  On the First Friday of each month, I present two business books.  And on the third Thursday of the month, I present one book on an issue of social justice (poverty; homelessness; racism; and other related issues).

The contrast between these two worlds, at times, is overwhelming.

So, as we think about building successful organizations, and succeeding in business, maybe it would be good to read a few books about those not as fortunate; those who never think about such things as organizational effectiveness, because they are simply trying to survive.

This month, at the Urban Engagement Book Club sponsored by CitySquare (that social justice gathering I speak at), I presented the superb, heart-touching book Rough Sleepers: Dr. Jim O’Connell’s urgent mission to bring healing to homeless people by Pulitzer Prize-winning author Tracy Kidder.

It is absolutely worth your time.  I hope you will read it.  It is the kind of book that will touch your heart and strengthen and expand your compassion muscles.

As always, I begin my synopses with What is the point? Here it is for this book: The people without a home face an array of problems.  Their numbers are increasing (increasing greatly).  There is no one simple solution. This book describes a way to view these people, and treat these people, with compassion and genuine humanity.

And I ask Why is this book worth our time? – Why this book matters!  Here are my three reasons for this book.

#1 – This book is a great set of stories about serving the homeless.

#2 – This book is a tutorial on the power of listening.

#3 – This book is a challenge to keep at it… the people need us to.

I always include a few pages of Quotes and Excerpts from the book – the “best of” Randy’s highlighted Passages.  Here are quite a few of the best of the best from my synopsis:

They often left the floor of the men’s bathroom littered with food wrappers, toilet paper, plastic bottles. The owners of the station could say with some justice that the traveling public shouldn’t have to put up with that kind of behavior. …Jim agreed with some of those arguments. “Rough sleepers aren’t generally good houseguests.” 

“At the teaching hospitals, homeless people had very few advocates, and the homeless were often assigned to residents and interns to practice and learn on.” …Many of the nurses at the clinic were in fact volunteers, working there in exchange for the chance to practice their art. “Caring for homeless people is one department of nursing where you get to spend as much time as you need with a patient,” Blakeney explained. “You have to spend a lot of time. Otherwise you won’t have any patients. That’s what attracted so many nurses to the Pine Street model.  There was no insurance company saying, ‘You can only have six visits.’ …And the nurses felt threatened: ‘We don’t need medicine coming in here and changing what we do’.”

…an injunction against insisting that anyone had to be healed. “Just give love,” it read in part. “The soul will take that love/and put it where it can best be used.” 

“Charity is scraps from the table, social justice is a seat at the table, and remember, we want a seat.

It was obvious that he and his colleagues weren’t addressing the many root causes of their patients’ misery.   

This was Jim’s summary of the case: “Santo had lived in the Pine Street shelter for forty years. It was the world he knew. And if he was dying, he wanted to be around the people he knew. So I realized, you know, more power to him, because he was going to continue to drink his vodka and be with his friends. What I did for him didn’t seem right from the perspective of the person we were trying to serve.”   

“This is what I was trained for. I wanted to take care of people who were sick. And, oh my God, have I landed in a world where people are sick.”   

“The good days are so good and the bad days are so bad. It has to be almost a calling.”   

…a “recovery coach” who helped the patients deal with addictions… 

Of course the Street Team worked downstream from childhoods, where it was too late for prevention. But sometimes repairs were possible.   

But if you belonged to the team, you knew that recovery from the cycles of chronic homelessness was possible. …You could also cite the four members of the Program’s board who had once been homeless. 

Small human betrayals also added up.  

But this was the dissertation Tony offered on prejudice during a session in Jim’s exam room: “Some of these guys use the N-word connotative and denotative. My belief’s in this. Be very open, don’t judge a person by race, religion, sexual preference, political beliefs, or other aspects. When you start judging a person by their weight, their color, their disablements—there’s different forms of prejudices. And one of the things that we do when we do those things is we close our minds. Sometimes we do it in an ignorance way.”   

On one of those occasions, he cited large population studies about the tight connection between health and educational status. If he had the power, he said, he’d pay public school teachers $ 200,000 a year and maybe thirty years later homelessness would become a rarity. Maybe what he called “the faucet” would be turned off.   

And then, I move to key points and principles from the book.  Here is much of what I included from this book.  (Note:  anything in italics comes directly from the book):

  • About Dr. Jim O’Connell
  • bartender… and then, a Harvard educated medical doctor with a heat of gold and a great, great ability to listen.
  • He once told me that about three-quarters of his job had more to do with social work than medicine. And, he would say, it wasn’t medical school that had trained him for that, but rather the bartending he’d done to put himself through medical school. “If you’re not willing to listen to lots of people talking at you, not all of them coherently, you’ll go crazy tending bar.”
  • Pre-admiration was something like the opposite of prejudice, a quality the doctor had tried to emulate: “I think that Jim has an attitude of pre-admiration for the people he doesn’t yet know. His presumption is, ‘Oh, I’m eventually going to like this person. I will probably find some reason over time to like them. I just happen not to know it yet.’”
  • “Most of the patients I’ve been close to over these thirty-two years are dead. So there’s a certain sadness and moral outrage that I can’t get rid of. But when you work with people who’ve had so little chance in life, there’s a lot you can do. You try to take care of people, meet them where they are, figure out who they are, figure out what they need, how you can ease their suffering. I was drafted into this job, I didn’t pick it, but I lucked into the best job I can imagine.”
  • Mostly he listened, a bartender’s art, while the man, a tough guy from Manchester in obvious agony and trying not to show it, told about the mistakes he’d made as a kid and how he’d ruined his marriage and earned his children’s enduring anger.
  • After three years of 110-hour weeks inside Mass General, he had absorbed both its general code—to pursue excellence in medicine—and also a corollary, which was not to mistake yourself for an ordinary doctor. Jim felt he’d been “conscripted.”
  • Jim always stood to greet his patients. He would put on a listening smile for the talkative ones, all the while observing them carefully.
  • He always wore a collared shirt and necktie—his office uniform ever since Barbara McInnis had told him that patients expected him to look like a doctor and not a homeless person.
  • Jim was the institutional memory in the room. 
  • Some stories
  • the night-time van excursions – like old-fashioned doctors house calls
  • In 1986, the state financed what became the first of the outreach vans—“ The Overnight Rescue Van”—
  • But once he began riding the van three nights a week, he realized that he’d never met most of the city’s rough sleepers.
  • foot soaking
  • You filled a plastic tub halfway up with Betadine and put the patient’s feet in it. And, in keeping with an old rule left by the founder of the Pine Street Inn, you always addressed the patient by his surname and an honorific — “Mr. Jones.”
  • Foot soaking in a homeless shelter—the biblical connotations were obvious. But for Jim, what counted most were the practical lessons, the way this simple therapy reversed the usual order—placing the doctor at the feet of the people he was trying to serve. …This new approach was entirely different, and, he began to realize, it was much more effective clinically, at least with homeless people. And foot soaking was the perfect way to begin.
  • When they came into the clinic, they were usually exhausted, and their feet were sore. They’d let you look at their feet before they’d let you examine any other part of them. …After he applied it, patients were always grateful for relief from the incessant itching, and many were willing then to talk about invisible things that were bothering them.
  • Jim and a colleague made a small study of death records. It suggested that patients with a history of frostbite—or of trench foot—had a death rate seven times higher than other homeless people of the same age group.  
  • Tony!
  • Jim’s response was also predictable, in keeping with a longstanding, informal rule for the respite: “Make sure people feel welcome when they come to McInnis House, and don’t make them feel bad when they leave.” …Afterward, Jim commented on this latest desertion: “Things change like mad from day to day, but not much in the long haul. Sisyphus again. Tony’s the quintessential example for me.”
  • Eventually, though, Tony would visit the office and afterward Jim would get out his can of air freshener and spray the room. This was one usual sign that Tony would soon need to get off the streets.
  • Tony liked suspenseful action and adventure novels, and also Freud and Jung. Abraham Maslow was a special favorite.
  • But I don’t think we judge—at least I haven’t—we don’t judge people on what led them here. It’s what they do once they’re here. And Tony was the character on the stage who handled that best. 
  • So many homeless people
  • But the problem was driven and sustained by many long-brewing problems: the shabby treatment of Vietnam veterans; the grossly inadequate provisions that had been made for mentally ill people since the nation began to close its psychiatric hospitals; the decline in jobs and wages for unskilled workers; the continuation of racist housing policies such as redlining and racially disproportionate evictions; the AIDS epidemic and the drug epidemics that fed it. Also the arcana of applying for Social Security disability—a process so complex that anyone who could figure out how to get assistance probably didn’t need it.
  • Homelessness grew rapidly during Reagan’s time, and it continued to grow with every presidency that followed.
  • Homelessness exists in virtually every country. …According to a 2020 report from the United Nations Human Rights Council, more than 1.8 billion people worldwide lacked “adequate housing,” and about 150 million were homeless. …the United States had a problem similar to some of western Europe, a bigger problem than the Scandinavian countries, and a much bigger problem than Japan or South Korea. …between 500,000 and 600,000 Americans were homeless.
  • Counting only public school students—no parents or siblings, just the students—the federal Department of Education found that about 1.4 million suffered homelessness during the 2018–19 school year. Many nongovernmental estimates placed the yearly total of homeless people at 3 to 3.5 million, but those figures were based on a single study made by the Urban League in 2001—a study that, twenty years later, had been referenced at least 597 times, a case of references referencing one another, all based on one estimate. …there were still no certainties in this arena, except for the fact that homelessness was much larger than usually asserted, and no one knew its real dimensions.
  • Many Americans also lived in a state known as “housing insecurity”— …10 million American households were suffering such insecurity in 2019— …Looming evictions and rising costs for housing all but guaranteed that the ranks of homeless people would continue to grow, a threat already manifest in many places, such as New York City and Los Angeles. 
  • Who are the homeless?
  • Homelessness had a complex taxonomy. …the “hidden,” such as the Street Team patient who slept in a rented storage locker. The “transitional,” by far the most numerous, fell into homelessness only briefly, while the “episodic” did so a few times a year. A smaller number—about 10 percent in 2018—belonged to the “chronic” category, living in constant or near-constant homelessness.
  • That chronic group had two main subgroups—those who spent most of their nights in homeless shelters and those who slept rough, on pavement and park benches, in doorways, ATM parlors, tents on the outskirts of towns. …about a third of “the chronically homeless” usually slept outside of shelters.  
  • When Jim spoke at the gala in 2018, 38 million Americans were living in what the federal government defined as poverty. For an individual, this meant a yearly income of $12,140 or less.
  • For a family of six, the poverty line was $33,740, about half the cost of a one-bedroom apartment in most inexpensive Boston neighborhoods. Poverty and homelessness were clearly related.
  • They were not uniformly shared. Black Americans represented only 13 percent of the population, but, by one estimate, 40 percent of all homeless people.
  • …for everyone trapped in it, the state of homelessness was poverty in its most visible, savage, and lethal form.
  • There is no one answer; or no one cause…(cf. M. Scott Peck: “overdetermined”).
  • Given the problem’s complex etiology, no single group can be blamed for all its constituent parts.
  • Complexity was another of Jim’s themes. …And a patient could be both “complicated” and “delightful,” sometimes simultaneously, at least to Jim.
  • For a long time, Jim had been at odds with what he called “the drive to be certain,” which he believed was inculcated in doctors during residency and which took time to wear off. …He favored something nearer to what the poet Keats called negative capability. “I like it when people on our team say, ‘It’s so complicated, I’m not sure what’s going on.’”
  • The obvious remedy for people without a place to call home is to provide them with a home. …Jim had written, more than a decade ago, his faux prescription for a studio apartment to cure all the ailments of Boston’s rough sleepers. But his views had changed in the years since Housing First arrived. Now he observed ironically, “Housing turns out to be more complicated than medicine. I wish we had a cocktail of drugs that would cure people of being homeless.” …what we see refracted are the weaknesses in our health care system, our public health system, our housing system, but especially in our welfare system, our educational system, and our legal system—and our corrections system. If we’re going to fix this problem, we have to address the weaknesses of all those sectors.”
  • Homelessness was fed by racism, income inequality, and a cascade of other related forces. These included insufficient investments in public housing, as well as tax and zoning codes that had spurred widespread gentrification and driven up rents.
  • It all starts with listening…
  • He remembered Barbara saying: “You have to let us retrain you. If you come in with your doctor questions, you won’t learn anything. You have to learn to listen to these patients.”
  • The Rough Sleepers
  • preferred the streets
  • “Look, Doc, if I’m at Pine Street, I can’t tell which voices are mine and which are somebody else’s,” he said. “When I stay out here, I know the voices are mine, and I can control them a little.”
  • they embraced their community
  • but…it was so dangerous; in so many ways… 
  • The Myth of Sisyphus:
  • In graduate school, Jim had studied Albert Camus’ essay The Myth of Sisyphus.

They had thought with some reason that there is no more dreadful punishment than futile and hopeless labor.” At the end of the essay, Camus refutes its beginning: “The struggle itself toward the heights is enough to fill a man’s heart. One must imagine Sisyphus happy.”)

  • “Jim, you’re a doctor. You’re not God. There are things you can’t fix.”
  • In Massachusetts, the people who lived mostly in shelters suffered a death rate about four times higher than that of the state’s general adult population. But the people who stayed outside year-round—the Street Team’s special patients, whom Jim had once imagined as “hardy survivors”—died at about ten times the normal rate. 
  • Jim especially admired the work of an old friend Rosanne Haggarty
  •  Rosanne had founded an organization called Community Solutions. …the project had helped to get 105,580 people housed. …Since then, Community Solutions had set out to help willing cities and counties achieve “functional zero”—defined as “a future where homelessness is rare overall, and brief when it occurs.” …For Rosanne, much of the overall problem lay with fragmentation among social service agencies, both public and private.
  • Her favorite slide displayed in sequence the forty-two different steps that six agencies and a landlord had to complete to get one homeless veteran housed in Long Beach, California.
  • All the relevant agencies in a city or region would be represented in a single command center.
  • The system would constantly improve itself through an “iterative cycle”—tackling a problem, studying the results, then doing the job better.
  • “a public health approach—science-based, data-driven, collaborative, prevention-oriented.”
  • Jim emphatically agreed with Rosanne when she said that the term “homelessness” failed to capture the complexity of the problem. …He agreed with what seemed like her fundamental goal: “Each person we see in the shelters and out on the streets, somebody has to own responsibility for knowing that person and getting them housed.”

And here are my five lessons and takeaways:

#1 – One person; ok, maybe two people – can make a massive difference in the lives of people.

#2 – The people who make a difference have to approach this vocation as a calling; not a job.

#3 – Everybody can serve, and make a difference.  Even a homeless person, who lives on the street much of the time; even with, and in spite of, his own massive problems. (The story of Tony).

#4 – What happened greatly impacts what happens…  Including especially what happened during one’s childhood.

#5 – With this problem growing – with the number of homeless people increasing to the point of impacting our cities – this is a problem we need to tackle with our best thinking and our best efforts.

Here is a question:  how many books do you read a year?  Now, how many do you read a year to touch your heart and help you think about the most needy among us?

Might I be so bold as to recommend that you add a few books about such issues to your yearly reading stack?  Start with this book.  It will touch your heart, and maybe help you think about that all important question:  what can I do?  What should we all do?

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