Living and dying on the street, across from a hospital: How to better help the homeless | Opinion

She was sitting at a bus stop. Wrapped in three layers of clothes, you might make nothing of her at first — until you remember that it’s May, in Miami. Baking in the heat, she had been waiting there for two days, alone, so disoriented that she couldn’t tell us her name. No bus was going to help her. What she really needed was just across the street: a hospital.

Our team of medical students from Miami Street Medicine, a student-run organization, found her while conducting a weekly street run to provide medical aid to Miami’s homeless population. Unaware of her surroundings, through fluid filled lungs, she was able to muster a whisper, “Help me.”

A few hours after we moved her, her lungs failed entirely and she was placed on a ventilator. Later, we learned that she had been hospitalized just one week before. It was obvious she did not have mental capacity to care for herself before this began. Yet, somehow, she was discharged back onto the streets, prematurely and without a plan, only to sit across from the hospital — waiting, not for a bus, but to slowly die.

Who is responsible?

Homelessness is a health crisis. Upwards of 46,500 people experiencing homelessness die each year in the United States, and this number is climbing. Life expectancy for people on the streets is two to three decades shorter than national averages. Chronic diseases and disabilities are exacerbated by life on the street. Deinstitutionalization, a failed policy of the 1980s that closed mental health institutions, has driven many with mental health issues into homelessness.

Stories like this one are not uncommon. You might think it’s the fault of a simple missed line in a chart, but you can speak to any number of hospital emergency or trauma doctors and hear the same story. No one wants to take responsibility for these individuals, so they are passed along. The net result of this so-called help is considerable harm. The pronouns and details may change, but the outcomes do not.

Patient abandonment — discharging patients prematurely without adequate planning — is a form of medical malpractice. The Florida Board of Health has a Discharge Planning Guide. Medicare beneficiaries are also actively protected by mandated discharge plans. The laws exist, the resources exist, but if this Miami case shows us anything, the follow-through does not.

The issues of homelessness evolve, but its roots are historic and racist. While America’s black population makes up 13 percent of the public, they are estimated to make up 39 percent of our homeless population. Slavery, Jim Crow laws, redlining — in each phase of U.S. history, our policies and system have deprived minorities of socioeconomic opportunities. Black and Latinx Americans make up a disproportionate fraction of those living in deep poverty, a strong predictor of homelessness.

In 1988, the Pottinger Agreement arose out of an ACLU case. It gave Miami’s homeless people basic rights and protected them from arrest or unwarranted seizure of property, based on the idea that life-sustaining activities such as being in a park after hours or sleeping in vehicles were unavoidable when homeless. This agreement was terminated in 2019.

Across the nation, criminalization of homelessness continues to be a major violation of basic human rights. Legislation that outlaws life-sustaining acts include street sweeps in which homeless people have property confiscated and are forced to leave an area. They solve nothing, but allow cities such as Miami to ignore the underlying problem; out of sight, out of mind.

COVID-19 only made matters worse. As housing insecurity sky rockets across the country, stay-at-home orders, park closures, and nighttime curfews gave more credence to those who sought to criminalize homelessness.

Bridging the gaps

Street medicine is the practice of bridging the barriers and gaps in care seen in homeless populations. It brings medicine to the streets and connects people to the resources they need. There are street medicine teams across the country, like this student-run one in Miami. They serve a vital role as a stop-gap, catching those that fall through the cracks in our system. We should not need them.

Homeless populations have always faced indefensible oppression. Although many aid organizations exist, they still find themselves without much voice. Who will advocate for the people experiencing homelessness? The Miami Coalition to Advance Racial Equity is a multiracial coalition of experts, organizations and people with lived experience being homeless. It is forming with the mission of ending chronic homelessness through the view of a racial equity lens, providing advocacy and a voice.

Coalitions like this have emerged countrywide. We need more of them. We also need more safety net hospitals to provide comprehensive healthcare to individuals regardless of income, housing or insurance status. We need to set higher expectations for these hospitals, demanding they keep to their mission and take care of indigent populations.

Today, the woman from the bus stop is stable. She is breathing on her own; however, she won’t be discharged until she has a safe place to go, with someone to care for her. Imagine if that had happened from the start. She might never have come so close to dying on the street, across from a hospital.

Sabrina Hennecke is an MD/MPH student at the University of Miami Miller School of Medicine, working as a founding member of Miami Street Medicine.