House Calls To The Homeless: A Doctor Treats Boston's Most Isolated Patients | KUOW News and Information

House Calls To The Homeless: A Doctor Treats Boston's Most Isolated Patients

Sep 29, 2015
Originally published on September 30, 2015 8:39 am

As a doctor who provides medical care to Boston's homeless population, James O'Connell and his colleagues are used to working in unusual locations. "We are basically visiting them in their homes, which are often under bridges, down back alleyways [and] on park benches," O'Connell tells Fresh Air's Terry Gross. "It's been an education for us over these years."

O'Connell is president of the Boston Health Care for the Homeless Program, which provides health care services at over 65 sites, including adult and family soup kitchens, detoxification units and corrections facilities. He writes about his practice in a new memoir, Stories from the Shadows: Reflections of a Street Doctor.

O'Connell has been caring for Boston's "rough sleepers," or homeless, since 1985. He says that homeless patients suffer from the same chronic and acute illnesses as the general population — with one crucial difference. "What we see ... frequently, are regular issues that have been neglected for years and years," he says. "So we see the natural history of illness that is usually interrupted by good preventive care."

Over the years, O'Connell has seen the ravages of untreated frostbite, AIDS and diabetes, as well as the effects of profound isolation and extreme loneliness. But he has also witnessed a courage and resourcefulness in his patients.

"These are people who are nameless and faceless when they are sitting out in the street," he says. "But when you get to know them, they are stories of great courage, of struggles against unbelievable adversity. ... I think I probably would've been a broken person had I lived through what they lived through."


Interview Highlights

On suspending judgment

I remember what came across is that whatever I thought of someone, when I first met them or first walked by them, it rarely panned out once I got to know them, and the stories that emerged from these people, what they have lived through and as you learn, each one is very different from another, but each one has a remarkable story. ... I hope in these stories what emerges is the real resilient spirit of people who have really, really been dealt a bad hand in life and suffer from all those social determinants of poverty.

On the result of homeless people not receiving good preventive health care

We ... see the end stage of many things. We often see pneumococcal pneumonia, for example, which probably should've been treated on Day 1 or Day 2; by Day 7 or Day 8 it can be very, very devastating. ...

As we learned the hard way ... these are people who were struggling to survive outside on the streets. They're interested in just being safe today or just getting the next meal or just getting a bed for the night. Taking care of an infection in their foot or diabetes or their hypertension is way down the list of priorities, which, of course, is really difficult for us doctors who think that should be the top of the list.

On the extreme illnesses he's seen

We see dramatic things that I never saw in medical school or often even in the textbooks. During this past year [we] have watched a man who had been outside for a very long time who has a pretty difficult psychotic disorder who got frostbite on both feet, really severely, came into our respite facility where we cared for him and he elected to not do surgery, and we spent the past year watching his feet fall off from auto-amputation, which is what happens at the end stages of frostbite. Most of our staff, including our nurses, had never seen anything as dramatic as that.

We will also see tuberculosis, things that you would be used to seeing in a Third World country much more than an inner city of a very medically rich world. We see all of the end stages of AIDS neglected because people were not able to get to treatment. ... If you are caring for a homeless population, you are really seeing the really both exotic illnesses as well as the end stages of chronic, common illnesses.

On hidden homeless communities

Even after I had been doing this job for almost 15 years thinking I knew every nook and cranny of the city of Boston, somebody pointed out to me that there were 20 people living in a tunnel under Copley Square. ...They came out only at nighttime; they spent their days down in the tunnels. And I remember going down there and meeting all these people for the first time and being stunned that most of them had been there the whole 20 years that I had been out. We always think we know a lot, but we keep our minds open to finding there's always a new place where someone can be.

On trauma homeless women face

For women to get to the streets we know that the journey is one that is very complex and almost always full of unspeakable trauma — sexual, physical and emotional trauma — and, so, by the time women are on the streets, they are really suffering, and those who become pregnant often feel despair, discouraged, feel they have no place to go, and feel very attached to having the baby safely and in a good way.

So we found that pregnancy often is not only alarming for the women, but it's a place where they can actually take stock of their lives and try to come in, so we always try to provide as much service ... gentle service as we can to anyone who is pregnant on the street, so they can deliver a good baby and hopefully hang on to that baby.

Unfortunately, many of the women, if you speak to them on the street, have had many children, all of whom they've lost to social services, because they were unable to stop using or they had no place to bring the baby once the baby was born. There's an awful lot of trauma among the women on the streets about the children they have lost and mourn.

Copyright 2015 Fresh Air. To see more, visit http://www.npr.org/programs/fresh-air/.

Transcript

TERRY GROSS, HOST:

This is FRESH AIR. I'm Terry Gross. Homeless people who live under bridges, in subway tunnels and down back alleys are the medical patients of my guest, Dr. James O'Connell. He's the president of the Boston Health Care for the Homeless Program, the BHCHP, and is on the team of doctors who treats patients on the streets. The BHCHP provides health care services at over 65 sites, including adult and family shelters, shelters for victims of domestic abuse, soup kitchens and day centers, detox units and corrections facilities. O'Connell has been working with the group since its creation in 1985. It's now the largest and most comprehensive freestanding health care for the homeless program in the U.S. O'Connell is also an assistant professor of medicine at Harvard Medical School and Massachusetts General Hospital. He's written a new memoir called "Stories From The Shadows: Reflections Of A Street Doctor." Dr. James O'Connell, welcome to FRESH AIR. When you started doing homeless medicine right after your residency, you were told by nurses to always start treating a patient with a foot bath. What's that about?

JAMES O'CONNELL: I owe most of what I know as a doctor now on the streets to the nurses that's really took care of me. Although, they were quite harsh when I first started. I left my residency - my last job as a resident was to be in charge of the medical intensive care unit at Mass. General Hospital, which is a very busy place where the sickest people from the hospital are taken care of. And I remember thinking at that stage of my career that, wow, finally four years of medical school, three years of residency, I'm ready. I'm good. I want to go show the world that I can take care of people. And I went six blocks down the street to start my new job at Pine Street Inn, which is a remarkable shelter in Boston. It's actually New England's oldest and largest shelter. And I marched into the shelter. All the nurses were sitting around. And I thought they were going to be thrilled to see me. But in fact, they were very severe and explained to me that they had been taking care of homeless people for about 15 years without the help of doctors or hospitals, thank you very much, and that I would do well to just listen to them. And one of the nurses who became really my mentor and my hero was named Barbara McInnis. And Barbara said, what you should do - and she lifted my stethoscope from around my neck and put all my doctor stuff aside. And she said, for these next two months, I want you to soak feet. And I wasn't allowed to ask any medical questions. I couldn't say I was a doctor, or I couldn't do any of the things that I had been taught to do. And Barbara, by the way, I can remember her telling me that one of the problems was that when I was in training, we had to go to fast. And how was I going to learn how to slow down? And she was right, in fact. And, you know, when we're doctors, we have to see somebody every 10 to 15 or 20 minutes. And if we're not doing that, somebody knocks on the door to see if they can help us move along. And Barbara and the nurses explained that when you've been wandering the streets for years, you will not trust anyone unless they commit themselves to being there, to being present and take time. And I remember one person Barbara had me - whose feet had - she had me soak, was a man I had known many times in the emergency room at Mass. General Hospital. He suffered from a type of paranoid schizophrenia. And we had sort of labeled him treatment resistant. After about six weeks, he looked down at me. And he said, hey - never had said a word to me before. He said, hey, I thought you were supposed to be a doctor. And I looked up. And one, I lit up because it was the first person in the entire shelter that ever said doctor to me. And I said, I am. And he goes, what the hell are you doing soaking feet? And I remember answering. I said, I don't know. I just do whatever the nurses tell me. And he looked down with kind of his wry smile and said, boy, smart man. And that was the beginning of my relationship with him. He came in a few nights later and asked me if I could give him something to help him sleep. And I remember we gave him a medicine that was both a good sleeping medicine and a mild antipsychotic. He took that, came back a few nights later and said, it was pretty good, Doc., but I could use a little bit more of it. So we upped the dose. And that was the beginning of a one-month journey to him accepting and asking for the medications we had been spending 25 years trying to get him to take in the emergency room.

GROSS: Right...

O'CONNELL: And Barbara.

GROSS: So this patient, who seemed to be resistant, was now asking for medication.

O'CONNELL: Yeah, exactly. And he then spent the next 20 years in a group home instead of on the streets, not in the emergency room. And I remember thinking that, you know, he was not at all resistant to medications. We just had a system that was very impersonal and just didn't understand how to address his particular special needs. And I remember the nurses looking at me and saying, see? (Laughter). So that was a pretty good learning experience.

GROSS: More advice that the nurses gave you when you started working with the homeless was don't judge. These people have been through hell. Was that good advice?

O'CONNELL: That was the best. I think - in fact, when I think of the stories in this book, most of what came out - and I just would add that most of these stories were written sort of late at night, after I'd had a crazy clinic day. And I was just writing to sort out what it was that had just happened. So I remember thinking I wasn't really writing them to ever share them with anyone. But they were a way to just sort through a pretty difficult social situation for me, where I was trying to care for people caught in this web of homelessness. And it was tough. So I remember what came across is that whatever I thought of someone when I first met them or first walked by them, it rarely panned out once I got to know them and the stories that emerged from these people, what they have lived through. And as you learn, each one is very different from another. But each one has a remarkable story. And what I started to see - and I suppose through the nurses' eyes - that these are people who are sort of nameless and faceless when they are sitting out on the street. But when you get to know them, they are stories of great courage, of struggles against unbelievable adversity. And most of the time, I think I probably would have been a broken person had I lived through what they lived through. So I came to admire - and I hope in these stories what emerges is - the real resilient spirit of people who have really, really been dealt a bad hand in life and suffer from all those social determinants of poverty.

GROSS: You must see a lot of medical problems that most doctors don't typically see, including frostbite, maggot infestations. Describe some of the fairly typical medical problems you see among the homeless that you wouldn't see at your average internist's office.

O'CONNELL: Homeless people suffer pretty much from the same chronic and acute illnesses that we see in the clinics at the hospital and the health center with our primary populations. What we see though, frequently, are regular issues that have been neglected for years and years. So we see the natural history of illness that is usually interrupted by good preventive care, good medical care. So we do see the end of stage of many things. We often see pneumococcal pneumonia, for example, which probably should have been treated on day one or day two. By day seven or day eight, it can be very, very devastating. So I think what most of us learn as you care for homeless people is we're seeing illness too far down the list or down the line. And what we're trying desperately to do is get to people as soon as we can. And as we learned the hard way, if you wait for folks to come to you in the clinic, at least these are people who are struggling to survive outside on the streets. They're interested in just being safe today or just getting the next meal or just getting a bed for the night. Taking care of their - an infection in their foot or their diabetes or their hypertension is way down the list of priorities, which of course is really difficult for us doctors who think that should be the top of their list.

GROSS: Right. But you do see problems that doctors typically don't see. Like, you see people who have frostbite that's so bad their fingers or toes are falling off.

O'CONNELL: We - we see dramatic things that are - I never saw in medical school or often even in the textbooks. We, during this past year, have watched a man who had been outside for a very long time, who has a pretty difficult psychotic disorder, who got frostbite of both feet really severely, came into our respite facility, where we cared for him. And he elected to not do surgery. And we spent the past year watching his feet fall off from auto-amputation, which is what happens at the end stages of frostbite. And most of our staff, including our nurses, had never seen anything as dramatic as that. We will also see, you know, tuberculosis, things that you would be used to seeing in a Third World country much more than in an intercity of a very medically rich world. We see all of the end stages of AIDS, neglected because people were not able to get to treatment or couldn't get to treatment. So in many ways, we are still - if you are caring for a homeless population, you are really seeing the really both exotic illnesses as well as the end stages of chronic common illnesses.

GROSS: So you're basically making house calls on the street.

O'CONNELL: We do. It's an interesting upside-down world. I think of myself as working on a team dedicated to caring for rough sleepers, which is the name we often use for the street folks. But we are basically visiting them in their homes, which are often under bridges, down back alleyways, on park benches. And it's a - it's been an education for us over these years.

GROSS: Did you find out about communities of people living on the streets that you never knew existed before?

O'CONNELL: Absolutely. There is a - for example, even after I'd been doing this job for almost 15 years, thinking I knew every nook and cranny of the city of Boston, somebody pointed out to me there were 20 people living in a tunnel under Copley Square, where there's sort of an elaborate array of three tunnels where the Mass. Pike, the subway and the Amtrak lines go underneath there. And it turns out down in the dark rubble were 20 people living there. And they came out only at nighttime. They spent their days down in the tunnels. And I remember going down there and meeting all these people for the first time and being stunned that most of them had been there the whole 20 years that I had been out. So we always think we know - know a lot. But we keep our minds open to finding there's always a new place that someone can be.

GROSS: So how did you find out about that - that community, that home?

O'CONNELL: One of the nice things of our lives is that because we've been out there for so long, most homeless people have come to at least know us. And I would say most of them have come to trust us because we've been there. And they know that we're not there to come after them but to care for them. And so we usually find out by word-of-mouth. And it was - that time it was someone who was really worried about one of the women living under there who looked very ill. And they asked if I would just go down and take a look at her. So I was actually - actually was escorted down there - actually I asked some of the police who have to monitor that place to come with me. But I was asked by the homeless folks to go down there. And it was really wonderful that we did because it turned out it was a very sick woman who was pregnant. And we brought her in, and she delivered a healthy baby.

GROSS: You know, the women must have special health problems, women who are living on the street - because first of all, I'm sure there's a lot of rape and other, you know, just, like, sexual abuse. And - and being pregnant, living on the street must be a grave health risk both for the mother and the child that she's carrying.

O'CONNELL: It's quite dramatic and tragic. Women, I think, living on the streets - first of all, I would say that for women to get to the streets, we know that the journey is one that is very complex and almost always full of unspeakable trauma - sexual, physical and emotional trauma. And so by the time women are on the streets, they are really suffering. And those who become pregnant often feel despair, discouraged, feel they have no place to go and feel - feel very attached to having the baby safely and in a good way. So we've found that pregnancy often is not only alarming for the women, but it's a place where they can actually take stock of their lives and try to come in. So we always try to provide as much service and gentle service as we can to anyone who's pregnant on the street so that they can deliver a good baby, and hopefully they hang on to that baby. Unfortunately, many of the women, if you speak to them on the street, have had many children, all of whom they've lost to social services because they were unable to stop using or because they were - they had no place to bring the baby once the baby was born. And there's an awful lot of trauma among the women on the streets about the children they have lost and mourn.

GROSS: If you're just joining us, my guest is Dr. James O'Connell. He's the president of the Boston Health Care for the Homeless Program, which provides medical services for homeless people. He's also one of the doctors on the medical team that treats people on the streets. And he's an assistant professor at Harvard Medical School and Mass. General Hospital and author of the new book, "Stories From The Shadows: Reflections Of A Street Doctor." Let's take a short break here. Then we'll talk some more. This is FRESH AIR.

(SOUNDBITE OF MUSIC)

GROSS: This is FRESH AIR. And if you're just joining us, my guest is Dr. James O'Connell. He's the author of the new memoir "Stories From The Shadows: Reflections Of A Street Doctor." He's the president of the Boston Health Care for the Homeless Program, which provides medical services for homeless people. He's also one of the doctors on the medical team that treats people on the streets. When you're out on the street trying to treat people living on the street, what kind of supplies do you have with you? What's in your doctor's bag?

O'CONNELL: We have pared down what's in our doctor's bag to very, very little. What we have learned - and I learned this from the physician assistants and the nurse practitioners primarily that work on our team on the streets with - with us - that what we need to do is we learn how to take blood pressures, so we have a wrist blood pressure cuff, and we have a way to take a temperature which is very quick. We can also check somebody's oxygen level with a little finger thing we - it's called an oximeter. And what we've learned is on the street with very, very little equipment, you can triage people very well. You can get their vital signs. You can find their blood sugar. You can know their respiratory rate. And with that, you can make a pretty good decision whether somebody is sick or not sick. And when you're on the streets, primarily what you're trying to do is make sure people are OK and not too sick, and we've learned how to do that. We used to carry medications and bandages and all that. But where we are in the city of Boston is usually not more than a few blocks from either one of our hospitals. We work out of Boston Medical Center and Mass. General Hospital or near one of our own clinics in the shelters where we have tons of supplies. So we will just walk a few blocks, get those supplies and bring them to the street folks. So we've learned to pack lightly, and it makes it a lot easier when you're walking around, particularly in the wintertime when it's freezing cold. So what we do carry in our doctor bag, to be very honest with you, is fewer doctor things and way more things like socks and underwear and Dunkin' Donuts cards or McDonald's cards, things that are really valuable to people on the street in which we can use as engagement tools.

GROSS: The homeless people are targets for - for thieves and sadists. But I'd imagine in some ways, you might be a target when you're out in homeless communities treating people, even though the people know you. I mean, there's a lot of people who are mentally ill and who are having hallucinations and delusions, and they don't necessarily know who you really are or what you're doing if they're in the middle of a delusion. So how do you prevent yourself from being a target?

O'CONNELL: I think anyone who's doing street work has to be exquisitely careful and aware of how dangerous it can be. That said, I think - I would certainly say over these past 30 years, I can only remember once or twice when I've actually really felt frightened outside. Most of the time, I feel cherished and protected by those I'm seeing. But complacency is something we never - we never want to be or have because you are exactly right, you know, people are suffering and there's explosive disorders. There's lots of psychosis out there that are not the fault of the people themselves, but their behavior's a result of that. And you have to be cautious of that. One of the things I get to do and have been doing since 1986 is go out a couple nights a week on a van, which is run by Pine Street Inn. It goes out every night from 9 at night 'til 6 in the morning - 5 in the morning every night of the week. It's a remarkable outreach program that is staffed by people who are mostly - were homeless themselves or who are in recovery, but all of whom are people that have learned the art of never judging anyone. And this van - which I can remember back in 1986 I was hoping would be a medical van - the homeless folks who were involved in helping us set it up did not want a medical van. But they wanted something that would bring them soup and sandwiches and blankets and clothing, things that when you're living out on the streets would be really valuable. And so this van goes out every night and has learned how to engage folks. And if ever folks have taught me how to be careful, cautious and avoid problems - the violent problems outside - it's the group that I get to work with on that van on Mondays and Wednesdays. And I've also learned that, you know, I can serve a lot of soup and sandwiches and then mention to somebody that I'm also a doctor, and you'd be surprised how that breaks down many barriers.

GROSS: Yes. So what are some of the things you've learned about how to protect yourself?

O'CONNELL: We never get in the way of fighting. If someone is fighting, we've learned that you have to walk away from that. That was a hard lesson for me 'cause I wanted to jump in and try to break up a fight. We've also learned that when people are psychotic and - and yelling, we usually keep a long - a big distance and give them lots of room 'cause we realize that it's - it's explosive behavior that is uncontrolled that can be very dangerous. And so on the van, we have rarely really seen much violence. I'm trying to think in my mind of the last time, and I actually honestly can't think of it. But I think it's the brilliance of those people who are out there every night and know everybody and have learned the behavior patterns of the folks that are living outside. So I would say if you're going out in the streets and don't know who's out there, it can be very dangerous. But as you've been out there for years and know who's out there, which is really the - the benefit and the joy of familiarity, then you start to notice things much more quickly. So I - that's the caution I would have - if you're newly out on the street, I'd be very cautious. But over time, you'll get to recognize those patterns of behavior that you have to be careful of.

GROSS: My guest is Dr. James O'Connell, whose patients are homeless people living on the streets of Boston and in shelters. His new memoir is called "Stories From The Shadows: Reflections Of A Street Doctor." After we take a short break, he'll talk about memorial services for the homeless and having to figure out if the deceased has a family and if so, how to find them. I'm Terry Gross, and this is FRESH AIR.

(SOUNDBITE OF MUSIC)

GROSS: This is FRESH AIR. I'm Terry Gross, back with James O'Connell, a doctor whose patients are homeless people living on the streets of Boston and in shelters, soup kitchens, detox units and corrections facilities. He's the president of the Boston Health Care for the Homeless Program and author of the new memoir "Stories From The Shadows: Reflections Of A Street Doctor." You have treated a lot of patients who have died - not necessarily died under your care directly, but eventually died from living on the street. And you write about how some of the shelters do funeral services or memorial services. And I would like you to describe one of the funerals that you've attended for a homeless person who you treated that you found especially moving.

O'CONNELL: One woman who was from the streets who used to describe herself as a bag lady. And she would keep you and I away by having just the smelliest clothes she could. And her belongings were smelly, and she would put those around her so that it would protect her from anyone coming near her. And she developed - she drank and had gotten hepatitis C from a blood transfusion many years ago, and she needed a liver transplant. And it turns out if you're homeless, you have a very hard time getting a life-saving liver transplant unless you can show at least six months of residential stability and at least six months of being clean and sober. So we kept her in our facility for that time so that the transplant surgeons could have the documentation they needed. And I remember just before she was at the top the list, she called me over one Sunday morning and asked if I would take her picture. And I was not used to taking pictures of people's faces at that time. I used to take pictures of, you know, feet - frostbitten feet, et. cetera - that I can use for teaching medical students and residents how to handle some of those problems. But I took a picture and brought it back to her. She got all dressed up - put on a dress, put lipstick on, tied her hair up. She had a Styrofoam cup in which she put some flowers and put it next to her bedside table. And I took the picture, and I brought it back to her a couple of days later in a little frame and asked her what was going on. And she told me that she was facing this major liver transplantation, didn't know whether she'd live or die, but that she had not seen her daughters - two daughters - since they were 4 and 5 years old, and that was 25 years ago. And she wanted to be sure there was a picture of her in case her two daughters wanted to look and see what their mother - what had happened to their mother someday, and she wanted to be presentable. So I was blown away mostly because she was telling me - I think in graphic ways - what it's like to experience illness, suffering and the specter of death when you are homeless and have lost everything. And what I have learned about homelessness in our city and I think across America that it is about as lonely a situation as you can have. People are alone, ignored, kind of abandoned. And I think when they face death, they look at their lives and wonder, you know, what could've been - think about what could have been, wonder about stuff. And I shudder every time I think about what that must be like to really have lost even touch with your own children, have no family members, have no money and really no hope for a future that looks any better than living on the streets. But anyway, what was striking to me is when I came back into - I gave her that picture when I came back to - our McInnis House is what we call it - I think there were 22 people the next day that asked me to take their portraits. And it's...

GROSS: You have a lot of these photos in your book. Is that - so this is how you started doing that?

O'CONNELL: That's exactly how I started doing it. I was always - I thought it was being kind of voyeuristic to take pictures of homeless people. I didn't want to take advantage of the privilege I had of being in their lives to also take pictures, so I was kind of - it's all upside-down from what I would've once thought. But that was a long-winded way of saying that death - when people die, we really try hard to mark their death and to gather people around and celebrate and memorialize these folks. Many, as you know, we don't know where their families are. We don't know if that was even their real name. And when they die, they're in the morgue - the city morgue - until someone claims them. And if no one does, then they will be buried in a pauper's grave somewhere in the city, so we try hard to not only one - try to find the families - but two - if no family is found, make sure we have a memorial and mark the burial and passage of that person. And it's the other homeless people who really cherish and value that.

GROSS: So let me ask you, this - this photo that got you started taking pictures of the homeless patients that you treat, she wanted the photo taken so if she died, her daughters who she had lost touch with would see what their mother looked like.

O'CONNELL: Yes.

GROSS: Did anyone come looking for her?

O'CONNELL: No one ever came.

GROSS: That must have made you sad.

O'CONNELL: It did. It was really sad. But I think that's the - you know, there's a hope and a reality. And I think for - it's hard for most of us who have - still have things and have hope in our lives - it's hard to imagine being so far down the - you know, so far down that your - you know, your contacts with society - your isolation is so profound that you see no way out. And I think when you see the courage of how people respond to that isolation, it takes your breath away.

GROSS: The kind of work that you do treating homeless people is a kind of, like, compassionate work that is sometimes associated with - with people who are doing that as part of their religious beliefs. You know, like, traditionally, there were a lot of, like, nuns working in - you know, with the poor and, you know, nuns who were nurses working with the poor. I think of, like, Mother Teresa - I'm not trying to say that you're Mother Theresa or anything. I'm not trying to, like, over-dramatize, but I think - I think you know what I mean. And I'm just kind of wondering - just to segue a little bit - if you have any kind of spiritual practice that sustains you while doing this work.

O'CONNELL: No. I certainly - I think this work - everyone who does this work I think comes at it from, I would say, spiritual rather than a religious sense. You know, I grew up Catholic. I went to Catholic school with the nuns and had Christian brothers in high school and even went to Notre Dame for Catholic college, and I was very much in the social justice sort of liberation theology world. So I think some of the roots of why I do this is certainly based in that. But I think I learned this also from the nurses, and that's that this is hard work. And if you're doing it for a really spiritual, religious reason, it's hard to sustain it because you're not - your success doesn't come in that things - I'm not converting people nor am I trying to convert people. But what I think rather than that, I think most of us who understand that, you know, we all suffer from these dark sides. We're all broken in our own way. And God knows every time I hear that thing about Mother Theresa, I think, you know, Mother Teresa's probably a saint, but anyone who knows us and knows any of the people we work with will know that I am the furthest thing in the world from a saint. In fact, I struggle every day with my Irish guilt about all the people I've hurt and all the things that have happened in my life. But it's - I think it's a connection with that brokenness that actually keeps us going. I truly believe that people that we're taking care of on the streets really - you know, things got set in motion when they were 4 and 5 and 6 and 9 years old that overwhelmed them. And most of those things were not their fault, but they now are trying to live through their lives having been given nothing or none of the things that I was blessed with when I grew up. I remember Barbara telling me - Barbara McInnis - early on that it's really hard to work around saints and zealots because they are so passionate, so determined. And she would much rather work around people who are just doing this because it's a normal job and we can go have a beer after the day is over. And I think I got brought up in that tradition, as opposed to many of my friends who are - went and learned this from a shelter or a place that was actually part of a religious institution or a faith-based institution. And those places are remarkable - don't get me wrong - but I think - I wasn't - that was not my experience.

GROSS: OK, so Barbara McInnis, who you say, you know, prefer to work with people who saw this as, like, a job rather than a religious calling. You describe her as the only true saint you've ever known.

O'CONNELL: I do, and I say it for just the - just those reasons. Barbara was - she really was my hero. She was a nurse who was devoted to doing this. She was self-described very dumpy, frumpy, I guess is what she was oft to say. She had a very high-pitched, squealy voice, but was just genuine, down-to-earth. And she had no pretenses, said what was on her mind. And she got to know what I would consider virtually every homeless person in Boston back in the 1960s, '70s and '80s. And she commanded huge respect, precisely because she never took a title. She was proud of being a nurse. That's what she wanted to be. But she didn't supervise anyone, didn't want to run any programs. And she was magic. Whenever I was in trouble and needed to get someone to really come in because I was worried about their - this spot in their lung that was probably cancer, I could always go to Barbara. And Barbara would come in, somehow coax that person in with us because she had such command of that. And then when the day was over, we would go and, you know, have - I remember her favorite spot is Doyle's Pub in - which is a neighborhood pub in Jamaica Plain, where we all lived at that time, a part of Boston. And we'd have beer on Friday nights, or else she would insist we go watch "Miami Vice," which was her favorite program. It was just ridiculous. And I just look back on those days and realize those discussions were fabulous. She was - admired Mother Teresa, but she realized that she was no saint herself. She had too many flaws. And I started to realize wait a minute, I think maybe she is the real saint here and have always felt that.

GROSS: We should mention she died a few years ago after...

O'CONNELL: She did.

GROSS: ...A car accident.

O'CONNELL: She was an unbelievable human being, and I - I just wish she were still around. She would be 80 years old if she would be alive now.

GROSS: So she was a nurse. Like, working with homeless people, do you have, like, a special appreciation of nurses?

O'CONNELL: I have a huge appreciation for nurses since I - everything - I have an older sister, by the way, who's a nurse, so I've learned to - I've learned to live with nurses. She's the only other medical person in my family, so I've long lived under the spell and dictates of nursing, OK? (Laughter) But Barbara and the nurses I think just - just showed me a way of taking care of people that I had not learned when I was in the hospital or in the medical schools because we were - we were being asked to do something completely different. But Barbara just learned how to say if you're going to reach this population, you've got to just slow down, you have to get to know them, you've got to take care. And it was a revelation to me. And then every way along the line, when I needed to figure something out, I could always go to Barbara. And she had been through it all. I remember one night I was struggling. Some man had come in - this is early on - some man had come in and said he was going to kill himself. And I was in the shelter clinic. And I - that's an alarm for all of us in medicine, so I didn't know the quickest way to get him help. So I went over - went outside and asked Barbara to come in. Barbara came in, and she looked at the man and she said, so what's going on? He said well, I'm going to kill myself. And she said well, we don't accept talk like that here in the clinic. If you want to talk like that, please go outside in the alley and talk to whoever you want about it, but we don't talk like that. And I was horrified that you don't do that. And then as I learned later, Barbara had known this man for years, knew exactly where he was coming from. She knew how to handle him. And in fact, all he was looking for was some reassurance and that people knew him, and that was the way out. And I started to realize there's many, many ways to take care of homeless people, and the best ones are based on who knows that person best and who knows how to handle them best. And Barbara was constantly teaching us that.

GROSS: If you're just joining, my guest is Dr. James O'Connell. He's president of the Boston Health Care for the Homeless Program, which provides medical services for homeless people. He's also one of doctors on the medical team that treats people on the streets. He's written a memoir called "Stories From The Shadows: Reflections Of A Street Doctor." Let's take a short break here, then we'll talk some more. This is FRESH AIR.

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GROSS: This is FRESH AIR. And if you're just joining us, my guest is Dr. James O'Connell. We're talking about street medicine. He's the president of the Boston Health Care for the Homeless Program, which provides medical services for homeless people. He's also one of the doctors on the medical team that treats people on the streets. He's written a new memoir called, "Stories From The Shadows: Reflections Of A Street Doctor." So you have a baby now?

O'CONNELL: I do, yes.

GROSS: And I'm wondering if coming home is different for you just in terms of not wanting to take any communicable disease or, you know, body lice or anything home with you that you might have, you know, picked up from treating homeless people. And again, I don't mean to send uncompassionate. I'm just trying to be realistic about what you face in your life.

O'CONNELL: It's interesting you should ask that. I have not thought about that, to be honest with you. I - the answer's no, I don't tend to worry about that. I think after all these years, I've - you know, usually come home and think of myself as really - either I take a shower or else it's antiseptic. I've learned how to be a doctor in that sense. And thank goodness, so far our little girl, who's about to be 2 years old in another week and a half, has been really healthy. So I haven't thought about that. The things that I have thought about, which is a little bit stunning for me and a little bit tough, is that, you know, most of my life over these past 30 years has been, you know, sort of singularly focused on our program and being a doctor and being president. And it's nighttime. It's daytime. It's a lot of hours per week. It's 90 or 100 hours a week. And in setting up our program, there were an awful lot of things to do both at the political level and, you know, the city, state, national level, trying to set programs up like ours so that they can be sustainable. So I think I completely neglected the important parts of my life that I - when I look back on them, when you had mentioned spiritual stuff, I completely neglected that. But then, you know, sort of - I got my Medicare card in March. And Gabriella (ph) showed up in September. You know, and all of a sudden, at a way-too-old age, I've got this beautiful little miracle (laughter). And I started realizing I want to be home. I don't want to be at work. And watching, over these two years, her - you know, her joy, her sense of wonder, her - I would say she's enchanted by her own existence. And you can't help, as a parent, but look at this and be overwhelmed. So Jill (ph) and I are now working hard to see how we can pare our lives down so we can be home as much. So I don't go out on the street now at nighttime as much as I did. So rather than fear what I may be bringing home, I'm trying to be home more. And I - you know, I'm candidly aware that, you know, having a child at age 65 means I'm not going to be around for that child's life forever. And every moment, every second, becomes really important. And I guess after so many mistakes having been made in my life, the one mistake I don't want to make is looking back and regretting that I didn't spend enough time with her. So that's what I've been working on a lot. And that's been a whole - a whole new way of trying to look at my own life.

GROSS: So had you become a father earlier in life, perhaps you wouldn't have accomplished what you wanted to in terms of treating homeless people.

O'CONNELL: Right. You know, I don't know how much of this is trying to make myself feel better because I waited too long. But I - I am nervous that if I had to - if there's a good thing about having a child at this age, it's that my career has been set. And I am comfortable in my career. And I'm probably - if anything, I'm on the downside of my career rather than the upside. And I'm so thrilled that I am relatively redundant at work now. We have such extraordinary people that I work with. The other doctors and the nurses and the people are extraordinary. So I remember when I took the first six weeks of my - first six-week vacation of my life when Gabriella was born, I remember coming back to work and realizing that I don't think anybody had missed me, that I've become entirely redundant in my own program. And so I both took - I took great joy in that. At the same time, I was like, oh, my God, they don't need me. It's an awful feeling (laughter).

GROSS: (Laughter).

O'CONNELL: But it was kind of a release to know that, you know, there are - there's another part of my life that I can now address as well. But I don't think I could've done that very easily back when we were - when it was only a few of us. And if I didn't do that with sort of un-singular devotion, I guess, it would've been hard to - it would've been hard to do the program. So in that sense, I'm - it's a little miracle to have this little girl with us now. And I just hope I can keep myself healthy enough to watch her graduate from high school and college (laughter).

GROSS: Well, thank you for the work that you do. It's really been a pleasure to talk with you. Thank you so much.

O'CONNELL: Oh, wow, thank you so much. It's been an honor.

GROSS: Dr. James O'Connell is the author of the new memoir, "Stories From The Shadows: Reflections Of A Street Doctor." And he's the president of the Boston Health Care for the Homeless Program. Coming up, our TV critic, David Bianculli, shares his first impressions of the new version of "The Daily Show" with its new host, Trevor Noah. This is FRESH AIR.

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