Homeless people are some of the least healthy members of our society. Poor nutrition. Exposure to the elements. High rates of mental illnesses and substance abuse. But Boston has become an international model for how to provide health care to the homeless, and it's earned that reputation based on the work of one tireless and single-minded physician.
BOSTON — To understand why Dr. Jim O’Connell is so unlike most other doctors, visit him on a Monday or Wednesday night. You won't find him at home or at a medical clinic or hospital. He'll be in a van stockpiled with plastic-wrapped sandwiches, hot chocolate, warm blankets and dry socks. Two evenings a week, he rides around the city distributing these supplies to people who need his help.
And although many of us recoil when we encounter homeless people, O'Connell is drawn to them, laughing and reminiscing and conversing effortlessly with men and women who sleep under bridges and on subway grates.
O'Connell, 64, has been riding in a Pine Street Inn outreach van for more than 25 years, not practicing medicine in the conventional sense, but giving food and blankets and limitless time to people who live on the streets. Because he knows that if he can win their trust, he may be able to persuade them to accept medical care from Boston Health Care for the Homeless, the organization he founded in 1985.
At his clinics, including ones at Massachusetts General Hospital and Boston Medical Center, O'Connell cares exclusively for street people, or people who used to be homeless but now have housing thanks to his team. And this is where he transforms from outreach worker to traditional doctor.
Boston Health Care for the Homeless isn't a place; it's a network. O'Connell has spent almost three decades building the organization from six employees to 350. They include full-time doctors, nurses, dentists and psychiatrists in more than 80 locations. He's turned it into the largest program of its kind in the U.S. and a template for similar programs around the world.
Finding Himself In Someone Else's Accident
So it's all the more remarkable that, for a long time, O'Connell had absolutely no idea what he wanted to do with his life. His college years in the tumultuous 1960s left him feeling burned and raw. Mainstream society had no allure. Neither did a traditional job. Not that he had any prospects; O'Connell jokes that his bachelor's degree in philosophy from Notre Dame and his master's degree in philosophy and theology from the University of Cambridge in England made him "uniquely prepared for bartending and driving cabs."
So O'Connell spent his 20s wandering — working odd jobs, bouncing around the country. He taught high school in Hawaii. Waited tables in his hometown of Newport, R.I. Briefly enrolled in a doctoral program in New York City, then considered law school.
"Basically, when I would see something that looked interesting, I would do it, and I had this thought that I would never do anything longer than a year or two," he says. "I didn't have any career aspirations."
At one point he and a bunch of friends bought an old barn in Vermont and lived there for more than a year, mostly just talking and reading and baking bread. It was an idyllic life in many ways, but O'Connell knew there had to be more.
"I remember not being totally at peace with what I wanted to do or be," he says, "and I started to get more and more agitated about, 'I've got to figure out what it is I'm going to do.' "
Then, during a trip abroad in his late 20s, he witnessed a gruesome motorcycle accident. It happened far from any medical facilities, so O'Connell waited with the rider until help came.
"And I had this unbelievable discussion with him while his leg was broken in two," O'Connell recalls. "He talked about what his life had been like growing up. He cried for a little bit. But I realized I felt really comfortable in that spot after a while, and the conversation I had made me really wish I could help fix his leg."
That's all it took for O'Connell to decide to go to medical school. He had no background in science, so he chipped away at his prerequisites, taking courses in physics and organic chemistry. Several medical schools discouraged him from applying; they told him he was too old to purse a career in medicine. But he got into Harvard, arriving on campus at age 30 — and, to his amazement, he loved it.
Eventually he settled on becoming an oncologist and won a fellowship to Sloan-Kettering Cancer Center in New York. But then his chief of medicine had a request: Would he be willing to put off his fellowship for a year to be the full-time doctor for a new homeless program in Boston? When that happened, O'Connell says, "I cringed, groaned and thought, 'Oh no! After all this time I finally know what I want and they're going to derail me.' "
But since it was the chief asking, O'Connell felt he had no choice but to say yes. He told himself it would be like an urban Peace Corps, done in a year. He knew so little about homelessness at that point that he thought the Pine Street Inn was a hotel.
"The Hampton Inn was down the street and the Holiday Inn was down the street — Pine Street Inn felt like a place like that," he recalls with a laugh.
'The Nurses Are On To Something'
This was the mid-1980s, the era of deinstitutionalization, when mentally ill people were being moved out of state institutions and often ending up in shelters or on the streets. As a result, homeless people were flooding emergency rooms, burdening the health care system. Boston had gotten a grant from the Robert Wood Johnson Foundation to find better ways to provide medical care to the homeless, and O'Connell arrived at Pine Street, his new workplace, with swagger.
The shelter's veteran nurses were unimpressed. They limited O'Connell to soaking the swollen, damaged feet of shelter residents. He couldn't even have a stethoscope. With each passing day, he grew more sure he'd made a terrible mistake by taking this job. Then one night a very sick man whose feet he'd been soaking for a month spoke to him for the first time.
"He looked down at me," O'Connell recalls, "and he said, 'Hey, I thought you were supposed to be a doctor?' And I kind of went, 'Yeah.' And he said, 'Well, what the hell are you doing soaking feet?' And I said, 'I have no idea, but I'm doing whatever the nurses tell me to do.' "
That interaction started a little miracle. Until then the man had refused any medical treatment, but a couple nights later he asked O'Connell for medicine to help him sleep. Then he agreed to take another medication to control his schizophrenia. Soon after that, he moved into a group home, where he lived for the rest of his life.
"So I remember thinking, 'Oh my God, the nurses are on to something: Nothing changes in the life of a homeless person unless you can take the time to win their trust, be present — all the things that we don't get a chance to do when you're training in the health care system where you've got about seven minutes with each person or somebody's going to be on you to move on to the next person."
And O’Connell realized that while he knew how to treat pneumonia, he didn't know how to treat it in patients with psychosis and cocaine addictions. He encountered rare diseases, like diphtheria and trench foot. Medicine among the homeless was complicated, challenging and fascinating, and it required skills his Harvard training hadn't taught him.
"I was thwarted at every turn by whatever the socioeconomic issues were," he says. "Somebody needed insulin, but it needed to be refrigerated, but they're outside. They needed a needle to be able to give themselves insulin, but the shelters don't allow you to have needles because those are contraband. Just everything didn't work, and I needed to learn it all over again. And it was kind of delightful."
Clinics Anywhere Patients Might Be
The nurses taught him something else: If you wait for homeless people to come to you, you've lost the battle. So he began treating patients on the streets and setting up clinics anywhere homeless patients might be — domestic violence shelters, mental health facilities, detox programs, even a local racetrack.
"I remember after the first year saying, 'You know what? This is way too hard and way too frustrating to quit right now. I need another year.' "
Somewhere in his second year, O'Connell realized he was hooked. But he was haunted by what he and many of his peers used to think about doctors who treated down-and-out patients.
"We thought they were the docs that didn't make it, they were not very good, they were working there because they couldn't be anywhere else. So I remember one great fear I had: I did not want to go out and take care of a very disenfranchised, marginalized community and then be very marginalized by my own profession."
His solution was to partner with the city's top hospitals. He made sure medical students rotated through shelters. He demonstrated that treating homeless patients can require as much skill and ingenuity as any other medical specialty.
Headquartered in Boston's South End, Boston Health Care for the Homeless now has not only a network of clinics, but a 77,000-square-foot medical complex that includes a pharmacy and a dental clinic, as well as a long-term care facility called the Barbara McInnis House for patients recovering from surgeries and illnesses. It also offers end-of-life care, giving homeless people a safe, dignified place to die.
O'Connell's reach isn't limited to Boston. He's helping England's National Health Service design a better way to deliver care to its street dwellers, and he travels regularly to Los Angeles to help city and county officials there do similar work involving Skid Row, an area of downtown LA with one of the largest homeless populations in the country.
O'Connell is an advocate of the Housing First movement, which works aggressively to find apartments for homeless people, and a tool based on his research into the risk factors that lead to street people dying prematurely is now used in 65 U.S. cities and towns to prioritize which homeless people are housed first.
'The Perfect Career,' With Costs
If O'Connell has a regret about his work, it is this: that his devotion to his job and his round-the-clock workweeks have come at the cost of his personal life. He married briefly when he was in his late 40s, but that didn't last, and he has no children, which he'd wanted. The photos lining his office hallway are telling; they're pictures he's taken over the years of his patients, his proxy family. So he pleads with young doctors to find better balance than he has.
O'Connell acknowledges that caring for homeless people can be burn-out work, but he says he's sustained by how heroic he considers many of his patients and by the satisfaction he gets from making their lives a little gentler.
"I always dreamed that I'd find something that would inflame my passion, keep me from getting bored, stay ever more elusive, in a sense, so I never feel I've gotten control of it," O'Connell says. "And this is it. I found the perfect career."
As celebrated as he is, Dr. Jim O'Connell is exceptionally modest. At a ceremony in Cambridge in early November, when he was awarded the prestigious Albert Schweitzer Prize for Humanitarianism, the first thing he said when he took the podium was, "If anybody knows a large rock, I'd love to crawl under it right now."
Although it took O'Connell half his lifetime to figure out what he wanted to do, he's a powerful example of the impact one person can make. Proof of that is in the thousands of homeless men and women who've received top-notch medical care, and sometimes life-saving care, thanks to a vision he embraced 27 years ago.