This story is part of Southwest Michigan Second Wave's series on solutions to affordable housing and housing the unhoused. It is made possible by a coalition of funders including the City of Kalamazoo, Kalamazoo County, the ENNA Foundation, and LISC.

Yancy Barrett had been living in Kalamazoo's homeless encampments when an undiagnosed case of cellulitis caused his legs to swell.
 
He managed a painful walk to the Bronson ER. A hospital stay followed, and then he was out, hitting the warming shelters and doing a bit of couch-surfing.
 
Barrett wasn't completely healed, so he was hooked up with Street Medicine Kalamazoo.
 
We talked to him in October. Now housed, he's still in touch with the "street meds," as they're known in the homeless community.
 
"Pops" gets a checkup from Street Medicine Kalamazoo. "Dr. Alluri took a liking to me," Barrett says, with a grateful smile. "Told me to not go to the ER anymore, just call her. Like she's my personal physician!" 
 
Street Medicine Kalamazoo came out of the Western Michigan University Homer Stryker M.D. School of Medicine early in 2021. Their mission is to take healthcare directly to the most underserved population, the unsheltered. 
 
"It's the extreme of primary care," Dr. Sravani Alluri, MD, says. "It's everything that primary care is supposed to be doing, embodied by street medicine."
 
Alluri's field is family medicine. She's also the director of Street Medicine Kalamazoo. She, along with Dr. Nicholas Helmstetter, MD, and a team of students and residents, hold an open-air clinic Mondays near PFC and Wednesdays at Ministry with Community. The team usually has four to five members and a rotating group of students and residents attending to patients. 

More than 25 medical students and over 20 resident physicians have been involved in the program and all medical students and resident physicians have the option of rotating with Street Medicine Kalamazoo during their clinical training, so the number of those involved is expected to grow.
 
Director of Street Medicine Kalamazoo, Dr. Sravani Alluri, checks Pops' pulse.Alluri says involvement in the program "is an important experience for physicians in their early career. It exposes them to the social determinants of health in a very real, tangible way and shapes how they interact and engage with their patients."

Alluri and Helmstetter have seen how a lack of healthcare has a major impact on people living on the streets and in tents. Alluri estimates that about 10% of patients admitted to Kalamazoo's hospitals are unhoused. 
 
"They're very complicated patients. We admit them again and again because their conditions are just not getting treated outside of the hospital. They never make it to our clinics, they have a hard time adhering to the treatments that are prescribed to them," she says.
 
"There was one we admitted 42 times in the span of six months, never saw him in our clinic. And he never got any of the medications he was supposed to be on, like his insulin and everything," she says.
 
Living without shelter leads to many health hazards, from exposure to the weather to substance abuse, leading to a higher death rate than people with stable shelter.
 
"Pops" gets a checkup from Street Medicine Kalamazoo. Alluri points to studies out of Pennsylvania and Massachusetts that have shown that there is a much greater death rate among the homeless than in the general population. The Massachusetts study looked at unsheltered adults over ten years and found that "they are about ten times more likely to die (in that timespan) than the general population," she says.
 
The Guardian in February 2022 reported that U.S. deaths among the homeless have surged 77% from 2016 to 2020. COVID was a factor in 2020, but violence, untreated disease, and drugs were also behind the surge. More communities are turning to street medicine to deal with this rise nationally and internationally. There are now street medicine programs in over 122 cities in 29 countries on six continents.
 
Dr. Sravani Alluri, Director of Street Medicine Kalamazoo"We take care of both their acute conditions and their chronic medical conditions," Alluri says. "Some of the things that we see commonly are skin infections. We see a lot of respiratory infections as well, like just colds and coughs and sinusitis, things like that. We see a lot of injuries, they tend to get wounds often, so we're doing a lot of wound care for them. We've also treated fractures as well, so we splint for fractures. Generally, we try to get them in somewhere to a clinic but they never make it there, so we splint their fractures, and manage those." 
 
Chronic illnesses are an issue. "We're taking care of diabetes every day," she says. There is also mental illness. "We have a few patients who are schizophrenic, have paranoia, that we're taking care of. We've given long-acting injectable medications for them, that are active for a month, which has helped, I think." 
 
The team administers substance use treatment. "We have a lot of patients who use meth, who use heroin, and who drink alcohol as well, on a daily basis, so we do medication-assisted treatment for all of those conditions."
 
The doctors say they've also made breakthroughs in combating Hepatitis C in the population. Through testing and treating, "we've cured about six individuals of Hep C," Alluri says. 
 
Dr. Nicholas Helmstetter, of Street Medicine KalamazooHelmstetter says they're also working to stop the spread of Hep C with needle exchanges, a collaboration with Kalamazoo Harm Reduction of the COPE Network.
 
Overcoming barriers
 
Homelessness creates barriers that keep people from getting care. 
 
Alluri says that, contrary to assumptions, most of their unhoused patients have access to health insurance. Yet, "despite having health insurance, many of our patients experiencing homelessness are not able to access traditional healthcare services due to constraints like not having a phone to coordinate appointments, lacking access to the internet, and needing to prioritize finding food, water, and shelter. As a result, they get poorer quality healthcare and have greater rates of disability and death than their housed counterparts. Street Medicine programs try to address these healthcare gaps by taking services directly to where patients are staying, addressing both their health and social needs, and advocating for patients within the healthcare system."
 
What is needed, Alluri realized while attending a 2020 conference on street medicine, are doctors "actually going out to patients, and being able to provide them clinical services on site where they are.... Not expecting them to come to the clinic, not expecting them to go to ED (emergency department) unnecessarily for things that should've been taken care of in a clinic."
 
The team learned that not only do they have to meet the homeless where they are, with stethoscopes and pressure cuffs ready, they also have to be ready to connect with people who have broken connections.
 
Health care is made accessible "both by going out to them and also in the way that we teach our students and residents how we interact with them as well. A big part of it is, in this population, there's so much trauma that they've gone through — childhood trauma, abuse, trauma that they've suffered even in the healthcare system as well. We try to start with working on that trauma a little bit by utilizing a more-compassionate approach, by taking care of their medical problems as well as addressing their social situation," Alluri says.
 
"And building that trust takes time," Helmstetter says. "You have to be consistent. You have to show up, you need to return their phone calls, you need to follow through on what you said you would. Otherwise, you're just perpetuating the trauma and distrust... the stigmatization that they might have encountered in more-traditional clinical settings or emergency rooms or hospitals."
 
A Street Meds team member takes notes during an examination.Helmstetter recalls a person who had an infection that may have led to an amputation of that limb without treatment. 
 
"We worked with them over the course of a year, controlling the infection to the best of our ability with antibiotics and wound care, as we're trying to convince them to get into the hospital" to get surgery. 
 
But the person had "distrust of the medical system and past trauma," and they refused to go to the hospital to get surgery. 
 
Gaining trust, in this situation, "is limb-preserving," Helmstetter says. "This person loves to ride their bike. Just to keep them ambulatory and keep up their hope, even with some setbacks, is satisfying." 
 
In addition to medical supplies, Street Medicine Kalamazoo carries totes of health and hygiene products for the unhoused.After a year of care, the person did have the surgery. Helmstetter has heard that "they have started to make some changes, and people around them have noticed they're being more consistent with their medications and taking more charge of their healthcare.
 
"They didn't have this sort of motivation a year ago. And I hope we're a small part of it."
 
Triage 
 
The Street Meds team has learned the techniques of open-air triage, as used around the world in war or in working with refugee populations.
 
"Field medicine has been a thing for a while," Alluri says. "You can do most things, outside of more major surgeries — obviously, that needs to be done in an operating room, you can do all of those things with a sterile setup outside." 
 
The Street Meds team can do most checkups and care that can be performed in a clinic.They have tool carts full of almost everything they need, from examination tools to forceps for very minor surgery. "We can do everything that we do in-clinic," she says, "suturing, skin biopsies, incision, and drainage, all the primary care procedures basically." 
 
What they're hoping for now is, a mobile clinic -- something van-sized or larger to work as a traveling doctor's office.
 
When Kalamazoo Street Medicine began, they received grants from the Kalamazoo Community Foundation, the United Way of the Battle Creek and Kalamazoo Region, and the Michigan State Medical Society. This support continues, and the team hopes for more.
 
They've recently received grants that they want to put toward a mobile clinic. 
 
"My job is to listen first and help address their healthcare needs, so I can help them get into a better spot," says Dr. Nicholas Helmstetter of Street Medicine Kalamazoo."The mobile clinic will help a little bit because one of our gaps is, if we need to do more-sensitive exams and we're out on the street, it's hard to find a private space to do a pap smear on a patient, or look at those more-sensitive areas," Alluri says.
 
The funding gap for the mobile clinic is $50,000. Plus, "We really need to hire staff, that's the other thing we're looking for funding for," she says. Street Meds needs around $50,000 a year to do "just what we do now."
 
Street Meds' aim is to keep homeless people's health issues under control, to keep them from putting a strain on local hospitals. Ultimately, the work they do "saves hospitals money," she says.
 
Doctors can't fix everything
 
"I did not see the extent of the problem fully, before," Alluri says of Kalamazoo's unhoused. "I was driving by the encampments every day, I was seeing people who are now my patients with all of their stuff in a cart behind them, and didn't really think too much about it."
 
"We try to start with working on that trauma a little bit by utilizing a more-compassionate approach, by taking care of their medical problems as well as addressing their social situation," says Dr. Sravani Alluri, Street Medicine Kalamazoo Director.Alluri did her training and early work in India, where she cared for "low, middle-income populations, underserved populations.... And that's where my passion is, working with that underserved population."
 
But when she came here, "I didn't see it in Kalamazoo, and now it's all I can see."
 
She now understands "the things our patients are going through, the creative solutions that they come up with for different things, their safety, keeping dry, how to get money, how they get food. My eyes are a lot more open to it."
 
"Throughout my clinical practice in Kalamazoo I was seeing patients who were unhoused in the clinic or in the hospital, but I just didn't have the understanding of what their life looked like on a daily basis. Even in India, I worked with unhoused populations, but not with the same depth -- not going out to them, seeing how they were sleeping, how they were living. I just didn't know all that before."
 
Street Medicine Kalamazoo's open air clinic near PFC on E. Willard Street.Helmstetter agrees that few have a deep awareness of the homeless. "I would say, overall, media, and government do a really poor job addressing and increasing awareness about the unhoused population, and the issue nationwide and internationally. So physicians and non-physicians come with this predisposition, this prejudice about how and why of everybody's situation." 
 
He's been finding a lot of unique individuals. "Everybody has a different story, we're working harder to listen to those stories, bear witness to them, record them, do more-structured interviews with our patients."
 
He continues, "I have a lot more radical empathy and understanding than I used to, and realize that it's not their fault. And in many cases, it's the system's fault -- and I can't control everything and fix things, but that's not my job. My job is to listen first and help address their healthcare needs, so I can help them get into a better spot, at least in that way.

Photos by Fran Dwight, unless otherwise indicated. See more of her work here.