By Dr. George Berrigan
Published in December 2012
In March, 2009, the Psychiatric Outreach Project (POP) based at the St. John’s Kitchen expanded its medical services beyond psychiatric care to include family medicine care. Dr. Neil Arya had been providing weekly clinics for people who had psychiatric and addiction problems. When Evelyn Gurney, RN, and I joined the program we were able to provide two full day clinics at St. John’s Kitchen and half day clinics at House of Friendship and a half day clinic at Emmanuel United Church on Bridgeport Road in Waterloo. Fortunately, Dr. Rebecca Lubitz (a family doctor) joined our team two years ago working one day a week at St John Kitchen. Adding family medicine to the POP program expanded services to people who are homeless or at high risk of becoming homeless.
I was impressed how the POP team functioned as an integrated team doing front line, problem by problem, practical work to help marginalized people cope with the housing and numerous psychosocial problems of poverty. Although the team of outreach workers, social workers and psychiatric nurses has many varied backgrounds and ideas they share the basic belief that every human’s life has value and is worthy of being treated with respect, dignity, acceptance and compassion. The team does not attempt to coerce or control in an authoritative way. The care must be patient, sustained, consistent and sensitive to the individual stories and particular circumstances (content and context) of each individual. These are the basic rules of engagement for the POP program. This is how we earn trust enabling us to connect and collaborate more effectively with the people we care for in finding ways to meet their needs.
The medical care of the marginalized involves different barriers not usually encountered in the average family medicine office. These people have a much higher than average prevalence of serious mental health and addiction problems and some have various issues with the legal system. We deal with the usual family medicine problems, but often our patients are quite ill with problems such as liver disease (hepatitis C and cirrhosis) infections of the heart (endocarditis), acquired brain injury, poor dentition, lacerations and traumatic injuries. Many of our patients have little faith in the medical system due to numerous negative encounters with health personnel in the past. Maintaining their ID is an ongoing problem (No Health Card, No Health Care). They move often and so follow up and making appointments is difficult. The POP team often helps our people with providing transportation to local or out of town appointments since walking is the only transportation means they can afford. We forgo all fees for letters, forms and administrative costs. Our outreach workers spend much time helping those people who have limited education to complete bureaucratic forms and contact many government and legal agencies advocating on their behalf. The majority of the people we care for have no family contacts or social supports. This is a significant liability in maintaining health and we struggle to accommodate this.
Our clinics are often very busy, somewhat chaotic and the waiting room is often like Grand Central Station. This kind of work definitely takes patience and diligence but also requires competence, consistency and lots of common sense. We often encounter very serious psychiatric and addiction problems that requires strong collaborative team work utilizing the team members’ skills and promptly accessing other community resources. A family doctor working on his own would not be able to manage these complex and stressful issues. Our attempts to stick with people when they need the help the most takes a willingness to adapt to ever changing and often demanding problems. This grass roots, hands on work is challenging and requires much commitment. We have to accept that compliance will not always be there but must work with this reality without giving up on these people whom society has marginalized, stigmatized and victimized with shame and blame. We try to work, walk and even just wait with our people as long as they need our help.
To listen to their stories and appreciate the horrific adversities and deplorable abuses most of them experienced in their childhood and teens is alarming and overwhelming, but it makes you understand how wrong and unjust it is to judge people as inferior or less worthy because of cruel circumstances totally beyond their control. If you grow up in a living hell you’re unlikely to become an angel. To appreciate the difficulties and dangers of living on the street or in ridiculously inadequate and unsafe rooming houses is to see real social injustice in a prosperous country and makes you ask where the shame really belongs. Good communities should not be measured only by their prosperity and productivity but also by how well they deal with their problems.
Bridging the gap to the needs of the marginalized will have to be done by us who have the skills and means to do so. The poor don’t have a strong enough social net to enable them to attain stability on their own. Poverty in our country isn’t just about a lack of money but also a lack of humanity. “Do gooder” charity is not the solution, social justice and attending to the social determinants of health are what is needed. Homelessness won’t be solved by more holistic medical care or more access to health care but by safe homes and attending to the shocking lack of proper childhood development facilities in our country. The lack of adequate parenting and childhood abuse are major sources of addiction. We need to fix this or the problem will keep growing.
