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

“You didn’t have to believe God sent you. You were on hand just because a man fell off his motorcycle and got a compound fracture.”

Jim describes the moment he decides to become a doctor. He implies the difference between being present to support people who are ill or injured and assuming responsibility for curing or changing the totality of their circumstances. Kidder consistently cites moments where Jim must be reminded that he is not God and can therefore not take on the responsibilities better left to powers greater than him.

“It was one thing to treat the excluded and despised inside the great hospital, another to imagine treating them in dreary clinics elsewhere.”

This quote demonstrates how class systems impact both patients and the medical profession. Kidder analyzes the necessity of overcoming class distinctions to better treat people and the stigma that makes treating unhoused people less desirable than treating “typical” patients. Internal and external biases inform the quality of care that patients receive at hospitals, as Kidder shows throughout the narrative.

“[Nursing] has a component that medicine does not attend to—that’s the human being and the context in which patients find themselves.”

Barbara Blakeney describes the critical angle from which many nurses provide care—not only for unhoused Americans but also for their other patients. She suggests that a patient’s humanity, and not their illness, is the primary focal point.

“Just give love. The soul will take that love / and put it where it can best be used.”

Barbara McInnis gives Jim this quote from Emmanuel's Book: A Manual for Living Comfortably in the Cosmos by Pat Rodegast (1987). Later, Jim interprets this as her advice for how to treat patients at the shelter. The quote captures the need for patient-centered care when treating unhoused patients—a group of people grievously abused or neglected by almost all systems meant to support them in the United States.

“The Reagan administration had used a study of mental health problems among homeless mothers to argue against housing subsidies—to say in effect that families were homeless because of mental illness, not a lack of housing.”

In the early days of the Health Care for the Homeless Program, many members on the board resist performing research because of this particular study and the Reagan administration’s use of the results. This quote demonstrates how interpretations of houselessness inform its resolution—or its expansion.

“Almost always, they would add that he shouldn’t think they chose to live outside. Offer them someplace else besides a shelter and they’d gladly move in.”

When Jim begins to work more closely with rough sleepers, their testimonies contradict misconceptions about the role of agency for unhoused populations. Statements from unhoused people challenge the idea that people choose to sleep in the streets. Kidder depicts the sometimes-chaotic environments of shelters and the possibility of contracting illness or developing worsening symptoms of mental illness.

“At times Jim imagined that he and his colleagues were practicing something like wartime and post-earthquake medicine. It was as if he had been parachuted into another world that modern technologies had never reached.”

Kidder observes Jim’s experience working with the Street Team. He describes the clear divide between the resources and illnesses seen in hospitals and clinics versus those seen in the streets of Boston. His reference to postwar or disaster medicine suggests the catastrophic rates of illness among the unhoused population in Boston.

“Jim, you’re a doctor. You’re not God. There are things you can’t fix. You just have to do work.”

Barbara McInnis alludes to the God complex sometimes associated with the practice of medicine as well as the importance of direct action in the face of complex injustices. In both cases, the solution—as Barbara sees it—is to get to work.

“[I]n asserting that many people preferred the streets to shelters and were therefore homeless by choice, Reagan in effect conflated homeless shelters with homes.”

Kidder explores the Reagan administration’s role in perpetuating stigmas about houselessness. Reagan blames the unhoused population and not the systems that contribute to the alarming rate of houselessness in the United States. Jim’s many patients challenge the assumption that the responsibility of houselessness falls upon the unhoused population, complicating how the general and professional public understand the role choice plays.

“[Jim] 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.”

Jim’s experience working with people, rather than just patients, affords him the ability to change and shape the Health Care for the Homeless Program and its medical philosophy over time. The program’s philosophy is also greatly influenced by the nurses who train Jim to listen to the people in his care before treating them.

“Ninety percent, he told me, had been afflicted by substance abuse or mental illness or both. And at least 75 percent had suffered the physical and psychological effects of severe childhood trauma.”

The statistic cited above illustrates how many factors contribute to houselessness. Jim and the Street Team don’t treat single symptoms. Rather, they confront years of systemic interpersonal and institutional neglect and abuse that impact the health and well-being of their patients.

“About a decade later, doctors remained the highest-paid professionals in the United States, and made about three times as much as their counterparts in Europe. But as Starr had predicted, many practiced under work rules aimed at increased productivity.”

The Street Team’s practice of medicine runs in direct opposition to a productive, capitalist model that, as Kidder writes, has overtaken the medical community. The capitalist method prioritizes productivity and efficiency over patience, which stands in contrast to Jim’s patient-centric approach.

“[O]ver the first ten years [Jim] and his colleagues rarely had occasion to question the worthiness of what they were doing, simply because they were so busy doing it.”

The Street Team (and Kidder) frequently identifies the need for acting directly to treat the unhoused population. Much like Barbara McInnis frequently reminds Jim, one needs to treat unhoused patients, regardless of whether one can cure them or fix their lives.

“Medicine is not efficient […] It’s not supposed to be efficient. It has nothing to do with efficiency.”

Jim disagrees with a capitalist model for practicing medicine, which emphasizes efficiency over patient care. He feels that medicine is better practiced with patience, care, and time—much like the model that the program offers to its patients.

“People who had adapted to the exigencies of street life had no idea how to fill their time indoors.”

Kidder reveals yet another layer of complexity contributing to the pervasiveness of houselessness. Much like recidivism in the prison industrial complex, where formerly imprisoned individuals reoffend, it is not easy for unhoused people to adapt to an entirely new way of being. It’s not as simple as obtaining a roof over one’s head.

“This is what we do while we’re waiting for the world to change.”

Jim emphasizes the importance of action regardless of persistent issues such as houselessness. The results might not always be what the Street Team hopes for—and, throughout the narrative, they often aren’t. However, the team and Jim continue to push forward by helping one person at a time.

“[A]s an example of how to approach the problem of medicine in the United States, [the program is] worth looking at.”

The Health Care for the Homeless Program is able to view a patient in all their depth and complexity. As the speaker quoted above suggests, they are a worthy practice that should be available for all people seeking health care from providers. At the beginning of the narrative, Kidder explores the stark divisions between seemingly “better” medical care for patients who aren’t unhoused. As the narrative deepens, this idea begins to flip, such as when the speaker quoted above suggests that Health Care for the Homeless is in fact the example by which other medical practices should follow.

“They look at you like you made your problems, you’re an alcoholic, you’re a drug addict, you deserve what your burden is.”

Tony shares his experience in medical facilities and conveys the sentiment Kidder explores through the narrative—that people who are unhoused are solely responsible for their circumstances and for overcoming them. Tony adds that people sometimes even believe that unhoused people are deserving of their situation.

“Housing homeless people is mandatory. A human right. But I have long been skeptical of the drive to show that it saves money, because that leaves housing dependent on whether it saves money. Ridiculous. Who would ever say that Mass General exists to save money?”

Jim again speaks about the direct conflict between capitalism and medical care and housing unhoused people. He shows how ridiculous public policy is when asking the rhetorical question of whether a hospital exists to save money. The practice of productivity and efficiency explored earlier in the narrative suggests that it in fact does.

“It’s easier to hurt people than it’s hard to help people.”

Tony offers this statement during his court case. This observation captures the struggle to help people who are living on the streets in the United States and the many systems that perpetuate harm against them. The narrative argues that there is statistical and qualitative evidence that systems perpetuate harm, through inequalities and sometimes violence, at greater rates than help is offered.

“One thing I’m hearing is that we all want to be everything to everybody, and one thing we need to do is, not try to be that.”

Jim says this during a speech. It can be interpreted to mean that a generalized approach attempting to solve the complexities faced by medical patients is ineffective. By clearly defining professional boundaries and roles, patients are better served by their doctors, nurses, therapists, and government.

“I like to think of this problem of houselessness as a prism held up to society, and 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 egal system—and our corrections system. If we’re going to fix this problem, we have to address the weaknesses of all those sectors.”

Jim describes the dynamic and pervasive failures of many systems in the United States that play a part in houselessness and health. This runs in direct opposition to the examples Kidder includes from the Reagan administration, which places the blame and responsibility upon unhoused individuals.

“[I]t was hard to see how it made the city safer to keep a former sex offender in a state of houselessness and roaming the streets.”

Kidder critiques the criminal justice system and its treatment of Tony. He suggests that the many legal hoops that restrain Tony from maintaining housing only perpetuate harm and do not (or may not) protect the public from it.