Rough Sleepers: Dr. Jim O'Connell’s Urgent Mission to Bring Healing to Homeless People

Jim begins work for the program at the Pine Street Inn, a shelter for unhoused people, on July 1, 1985. He rides the Orange Line to the South End of Boston with nothing but a stethoscope and instructions to go to the nurse’s clinic. Though he isn’t sure what awaits him, he feels confident about his experience at Mass General and his profession thus far. Kidder says that maybe the only piece that feels truly daunting is the salary of $29,000, which Jim is to live on while he completes his year-long tenure.

As he approaches the inn, Jim notices the degraded neighborhood with abandoned lots and rotting chain-link fences. People wait in a long line for somewhere to sleep or for food. Jim enters the Pine Street Inn and moves through a lobby full of people toward the double doors of the nurse’s clinic.

The clinic in the Pine Street Inn is the first clinic run independently from other medical institutions and by nurses only. Barbara Blakeney, a nurse at Pine Street Inn, relays that nurses oversee the treatment of unhoused patients because their treatment in medical institutions—like Mass General—is deplorable.

The clinic at Pine Street Inn was founded first through donations. This history greatly shapes Dr. Jim’s reception at the clinic—very few nurses trust a doctor’s intrusion and the larger institution to which he is attached. The procedures and demands of standardized practices and insurance claims, Blakeney tells Kidder, run in direct contrast to how the clinic at the shelter operates. Nurses can spend as much time as they need with their clients to treat them in the best ways possible.

Jim feels wariness from the nurses as soon as he meets them—they don’t want a doctor who doesn’t know how they practice medicine to come in and change their methods. Barbara McInnis, a nurse with a reputation that follows her, treats Jim differently, however. A lay Franciscan and a gentle woman, Barbara reassures Jim that the nurses at the clinic do want a doctor—but that what he knows about medicine isn’t sufficient for what the clinic demands. She cautions Jim that if he hopes to reach the patients at the shelter, he’ll need to listen to them and get to know them.

She gives Jim a page from Emmanuel's Book: A Manual for Living Comfortably in the Cosmos by Pat Rodegast. It reads, in part, “Just give love. The soul will take that love and put it where it can best be used” (29). Jim interprets this as another way of saying that all he needs to bring to the people this team serves are patience and care. Most of the patients they work with carry severe trauma—both from their lives and, in most cases, as a result of previous medical care. Barbara instructs Jim to lose his stethoscope and begin soaking feet, telling him that if he truly hopes to serve the patients at the clinic, he'll need to let the nurses train him.

Jim soaks feet in buckets filled halfway with betadine for over a month before he begins to connect with some of the patients at the clinic—a process frustrating to him because he can diagnose patients by the condition of their feet and recognizes many who’ve fled the Mass General emergency room against medical advice. Eventually, Mr. Carr begins to rely on Jim and his medical advice.

Kidder observes the irony of doctors washing the feet of unhoused individuals in a shelter. He reflects that Jim realizes this is the fastest way to better care for the unhoused population, who spend most of their time on their feet and in flight. Through foot soaking, patients learn to trust their health providers, and health providers, like Jim, can learn to listen, take their time, and care for them. Kidder quotes a study from Jim that cites death rates eight times higher than the average population due to conditions like trench foot and frostbite. Feet as an entry point, it seems, is as crucial as any other part of the body.

During the first two years of the Health Care for the Homeless Program, a committee made up of two parties—representatives from city hospitals and advocates and people who speak on behalf of the unhoused community, including an array of nurses and founders and managers of shelters around the city—draw up a charter. The charter forbids mental health services, anyone participating in the program conducting research, and the use of volunteers except nurses. These practices are put in place to protect the patients. For instance, Kidder cites an incident where the Reagan administration uses a mental health study to explain that houselessness is not a result of a lack of housing but a consequence of untreated mental illness, thereby placing the responsibility, and the blame, on the unhoused population.

Jim disagrees with these constituencies—research, mental health treatment, and more people to volunteer would only serve the interests of the people they are trying to help, he feels—but there are other components to the charter that he agrees with. One such tenant is that the medical staff participating in the program actively seek out their clients throughout Boston as a team to continue their care. In this way, patients can expect consistency, at least regarding their health care team.

As Jim’s involvement with the program continues, the program has clinics spread throughout the city designed to treat the city’s unhoused population. The longer Jim practices, however, the more he sees the complex nature of houselessness and its impact on health. A patient being treated at the clinic tests positive for tuberculosis (TB) and has been living at the Pine Street Inn shelter for multiple months, which means that TB is rampant throughout the population staying at the shelter. Though their TB can be treated, many of the people staying at the shelter flee once they realize they’ve contracted the disease there, thereby making their intense regiment of medication impossible to maintain unless Jim and his team actively pursue them and work together with the community to help them recover, which they do.

The program establishes a small respite facility, where people can recover from illnesses and procedures with consistent care, food, and shelter. Around the same time, AIDS starts appearing in the unhoused population in great numbers and with great consequence—Kidder documents one of Jim’s memories where a patient presents with what Jim recognizes is a secondary infection due to a severely weakened immune system caused by AIDS. When Jim refers the patient to the hospital, they release him, believing he is just looking for somewhere to sleep. He dies on the streets of AIDS.

The respite soon fills with AIDS patients, and like in much of the United States in the late 1980s, people are dying at rapid rates as fear spirals. Nurses and patients alike ask Jim questions about whether they can contract AIDS by sharing a bathroom or a bed. With very little knowledge about the virus, and no way to treat it, fear, AIDS, and death plague the community. At the same time, the TB outbreak is also spreading. Jim’s year-long tenure comes up during this period. He writes to Sloan-Kettering, a prestigious oncology department where he is slated to begin following his time with the Health Care for the Homeless Program, to defer a year.

There is a high demand for treatment outside of the clinics since a lot of the people afflicted with TB flee shelters or don’t stay long enough for treatment. The AIDS and TB outbreaks incite the program’s first outreach van in 1986. This experience gives Jim an entirely different perspective of both the health and scope of unhoused people in Boston—a great deal of “rough sleepers” don’t ever appear in shelters or the health care clinics within them. Jim learns, through repeated visits and listening to his patients, that shelters are less a safe harbor than they are an overwhelming environment of chaos and voices. Jim likens his early experiences with the outreach van to wartime or disaster medicine. His team witnesses diseases that otherwise are not present in populations with continued access to health care and shelter, wounds infested with maggots, and cancers that grow in equal size to the heads on which they are found. Jim feels simultaneously overwhelmed and fascinated by the work, which is never-ending and grows in complexity the longer Jim works within the program.

He asks, for example, how it’s possible to treat HIV in someone who cannot find somewhere to sleep at night or diabetes for patients who have no idea where their next meal is coming from. Getting patients to stick around for long-term care is another challenge. Kidder details a story about Gary, a WWII veteran who is treated for a wound containing maggots. Instead of staying at the hospital to receive treatment for the wound, he leaves. When Jim later runs into Gary on the street, the wound is so infected that his leg has to be amputated. Through this experience, and many like it, Jim realizes that a “patient-centered” approach is critical to serving the unhoused population in Boston, even if some of the methods for this kind of care are unconventional.

Kidder provides an example of a man named Santo, whose cancer of the esophagus is so severe that he requires a feeding tube to survive. Jim arranges for him to stay in a nursing home so he can receive care, but he later spots Santo outside the Pine Street Inn surrounded by friends and pouring vodka into one end of the tube. Jim realizes that, though the best place for Santo’s care is likely a nursing home, Santo has lived most of the last four years in the shelter and wants to die somewhere familiar in the company of his friends.

Jim soon spends all his time working for very little pay—but he doesn’t complain about this. Instead, he feels that the role demands it. When the end of the week nears, Jim and his colleagues gather at Doyle’s, a local bar, for drinks and to decompress from the high stress and emotional toll of the job. Though Jim never shares this with the rest of his team, he often reflects on Albert Camus’s The Myth of Sisyphus, a book that explores the Greek myth where Sisyphus rolls a boulder uphill to no avail for the duration of his life. Camus draws the observation that the work itself brings joy. This myth, Jim feels, is a great metaphor for the program’s efforts and the joy in the struggle. He shares his feelings of defeat with Barbara when they arise, and she tells Jim to remember that his job isn’t to fix everything; it’s to mend the illnesses or injuries in front of him. Jim declines the offer from Sloan-Kettering, realizing that what he wants to do is take care of sick people and that the program is the surest way to do that.