Helping Close to Home

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Phillip is having a tough day: His knee brace got stolen again. There’s a bone in his knee that pops out to the side when he walks, and it hurts to straighten the leg back out. That’s the thing about the brace: It keeps the bone in.  

Jessica Guido, a third-year student at the University of Arizona College of Medicine – Phoenix (COM – P) and one of the many tireless volunteers who keep the Street Medicine Phoenix program running, kneels next to him and starts going over some basics: How long has it hurt? (“Since ’91.”) Do you have any ongoing health issues? (“Healthy as a horse.”) Do you want any Tylenol or ibuprofen? (“I’d rather feel the pain, so I know how not to move it.”)  

As they talk, Guido’s eyes drift up from Phillip’s knee to his shoulder. “Oh,” she says, startled. “Your shoulder’s popping out.” Yeah, he says. He took a header over his bike handlebars last year and messed up his collarbone. He was supposed to get surgery on it, but he doesn’t want to risk it getting infected while he’s on the street and is worried a sling will bother him in the heat. Really, what he could use right now is a cough drop. “Do you have a sore throat?” Guido asks. “No, a toothache.” Where? “Anywhere there’s a broken tooth,” he says, opening his mouth. 

Like a lot of patients who stop by SMP’s station that morning, Phillip has a story of cascading, interrelated circumstances: Not just the knee, but the collarbone; not just the collarbone, but the teeth; not just the truck that broke down or the job he couldn’t get to or the housing he eventually couldn’t afford, but the whole undifferentiated mass. It happened gradually, he says. But now that he’s in it, it feels like the only way out is all at once. A volunteer comes back with not one but two knee braces. “Your shoulder,” she whispers, covering her mouth. 

We are in the lobby of the Lodestar Day Resource Center, a cinderblock building in downtown Phoenix that serves as a hub for a variety of homeless services including mental health counseling (through Community Bridges), employment support (through St. Joseph the Worker), ID and Social Security assistance (through the Homeless ID Project), religious services and so on. There’s a bathroom where people are washing up and a row of outlets along a wall where people are charging motorized wheelchairs. In the corner is a vending machine stocked with naloxone, a nasal spray that has proved miraculously successful in counteracting the effects of opioid overdose. A TV on the wall plays “Sanford and Son” on mute. There’s a feeling in the room of waiting, but also of having nowhere in particular to go. 

SMP has been setting up here roughly once a month for the past four years. Tomorrow, they’ll provide similar services at a nearby church. Over the course of two days, I witness everything from wound care (a man named Dave’s leg is weeping from his knee down to his ankle) to conversations about cholesterol and processed food. Some people just show up for the electrolyte solution and a clean pair of socks. “We might be the only provider these patients are seeing for the next six months,” Guido says. “It’s all about organizing things into what the patient wants addressed most.” 

For clinicians accustomed to being in positions of authority, the experience can be a fundamental shift. “Not patient-centered care,” as Brett Feldman of the Keck School of Medicine at the University of Southern California described it in a 2020 TEDx Talk, “but patient-led care.” 

Prior to the arrangement in the Lodestar lobby, Street Medicine Phoenix would do what its name implies: Go directly into the street and offer help. It wasn’t as simple as it sounds. Many of the patients SMP was dealing with didn’t want help, or had been burned by experiences with doctors in the past, or operated with a general mistrust of almost anyone in a position of institutional authority, whether city officials, police, doctors or otherwise. (When asked how long it had been between his last doctor’s visit and his first check-in with SMP, one patient cut me off and said, “I don’t go to doctors.”) 

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“We’re trying to re-establish communication between people experiencing homelessness and medical care they are fed up with, so that they might be receptive,” says Robert Fauer, a former family physician who spent 40 years running a private practice in Phoenix and Scottsdale before volunteering with SMP in 2021 and eventually becoming the program’s medical director. “A lot of them are angry.” 

It’s a messy process, but it seemed to work. Fauer remembers trying to disseminate COVID-19 vaccines to people in homeless camps at the height of the coronavirus pandemic. “Maricopa County had set up a tent,” he says. “After an hour, we gave out four vaccines.” They decided to go out and start tapping on tents individually, starting conversations, cultivating a little trust. By the end of the next hour, they’d given out all their vaccines. “It’s like they weren’t going to come to us,” he says, “but we could go to them.” 

The city’s largest homeless encampment — one of the largest in the country, in fact — was a roughly 15-block section of downtown known as the Zone. In the general freefall of the COVID-19 moment, the area’s violence, property damage and open drug use felt like an expression of America’s biggest problems in their rawest forms: the housing crisis, the opioid crisis, the ever-proliferating numbers of people on the street. 

“A thousand people, like you would expect to see in Southeast Asia or Africa or the Middle East,” Fauer says. Catherine Miller ’22, SMP’s outgoing lead, says that as a kid she dreamed of joining the Peace Corps to work with refugees. “I ended up seeing a refugee camp in my backyard,” she says. 

In 2022, local business owners filed a lawsuit against the city of Phoenix on the grounds that conditions in the Zone constituted a humanitarian crisis. They won. The effect was to precipitate a massive, block-by-block clearing of the area, forcing people like Phillip to squeeze onto the already overcrowded waitlists for temporary housing or figure it out on the fly. More recently, the city banned urban camping. 

Now Phillip gets arrested for sleeping outside and comes back to find his campsite trashed. (“It just gets harder and harder to establish yourself,” he says. “What kind of life are we supposed to have?”) “For now, we’ve shifted from street medicine to something more like mobile health,” Dr. Fauer says. “Instead of being on the street, we go to the church, we go to the S.O.S.,” or Safe Outdoor Space, a new, small, gated campsite managed by the city. Whatever street outreach they do — a Friday- night event aimed at drug-addicted people held in the parking lot of the Society of St. Vincent de Paul, for example — is done on private property with consent of the property owners. “I keep letters of permission from the owners in case the police show up,” he says — his papers, as it were. “The city was sued,” he says, shrugging. “The suit says they can’t allow camping. They have to shelter those people. It wasn’t just to be punitive.” SMP adapts.  

The history of modern street medicine starts with James O’Connell, a Harvard professor who started going on night rides in the mid-1980s with a group called the Boston Health Care of the Homeless Program in an effort to offer medical outreach to the homeless, who were dying on the street in startling numbers. “Rough sleepers,” the BHCHP called them; the term later became the title of a bestselling book. 

In the early 1990s, a doctor named Jim Withers at the University of Pittsburgh’s UPMC Mercy hospital started similar outreach efforts after overhearing two colleagues refer to a man who’d frozen to death on the street as a “bumsicle.” “That man haunted me,” Withers said in a 2015 TEDx Talk. “Our hospital was supposed to be a place of healing, but he’d chosen to face death rather than to accept our care, and instead of asking ourselves why, we dehumanized him.” 

After some social conditioning (“Don’t dress like a doctor and don’t act like an asshole,” one patient advised him), Withers managed to make inroads to a population the health care system had conventionally ignored, if not outright avoided, eventually founding the Street Medicine Institute in 2009. “House calls to the homeless,” he called it. 

Street Medicine Phoenix was founded in 2017 by then-students Jeffery Hanna ’17 and Justin Zeien ’17 ’21 and established within the U of A’s Mel and Enid Zuckerman College of Public Health. The concept was similar to Boston’s and Pittsburgh’s: Bring basic medical care to people who need it most. “As I was applying to medical school, I was constantly thinking about what sort of programs I could implement to serve underserved populations — to really address the health inequities that exist in those populations,” Zeien said in a 2021 interview. “Our ultimate goal is really just to meet people where they’re at. And, in a humanistic, dignified way, really restore them to where they want to be in life.” 

But the program also is an opportunity to bridge the gap between public health and medicine in a way that amplifies the impact of both. “Medicine isn’t just a treatment, it’s advocacy in the community,” Guido says. 

“I think we could probably do a better job as standard physicians in making sure we’re clinically addressing [medical needs] but also understanding the setting and type of population you’re treating.” 

“I can’t tell you how many patients I’ve seen on street runs walking around with humungous infected wounds on their legs, and they come up to ask for a Gatorade,” says Miller. “There’s 30 people in scrubs standing around with stethoscopes around their neck. [Health] is not the first thing [the homeless] think of by any means.” One patient on Sunday morning — Patrick, former smoker, high-blood pressure, diabetes — jokes with his student provider that her medical insights are great but that she needs to work on her chitchatting. (He uses a less delicate term for it that starts with “bull.”) “You never have to worry about talking to homeless people,” he says. Some days talking is what he needs most. 

“When someone tells you to look for a red car, you find red cars,” says Miller. “When you look for medical conditions, you see them everywhere. It’s almost like this deep prioritization of long- term issues compared to, ‘what do I need right now?’” Patrick says SMP saved his life. 

“When I started out, we had one little wagon,” Fauer says. “By the time I took over as medical director, I’d purchased a car.” Then came a van. Two years later, a trailer. The program now coordinates volunteers from three universities — the U of A, ASU and Creighton University, in Omaha — and the Mayo Clinic on a shoestring budget and a patchwork of small grants. With the exception of a rotating group of supervising physicians and a few support staff, it is entirely student run. 

“I grew up in Phoenix,” Guido says. “I went to undergrad [at ASU]. I’ve seen how underserved our unhoused population is.” She joined SMP as soon as she started at COM – P in pursuit of what she describes as the program’s “radical accessibility.” “I thought it was just really inspiring to see such a big group of people who are so dedicated to going out and meeting the patients where they were, literally and figuratively.” 

Andy Gontko, one of the program’s co-leads, says SMP was one of the reasons he applied to COM – P in the first place. He’d grown up in the Chicago area, volunteering at a homeless shelter as a teenager before moving to New Orleans to study chemical engineering at Tulane. “I love to walk, love to bike,” he says. “I met a lot of people who were unhoused, and just talking with them — that’s something I knew I wanted to get more involved with.” 

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Gontko says he probably could’ve made a bigger impact on more lives had he taken his engineering degree into pharmaceutical development, but he couldn’t shake the prospect of getting to meet people face to face, “to at least feel like you’re making a difference and seeing those cases, meeting those people that you’re actually making the difference for.” Then he says something remarkable for someone spending so much of his free time volunteering with the homeless: “In that sense, I made the selfish choice.” 

Fauer’s own conversion moment came in the wake of the subprime mortgage crisis in the late 2000s. “A million people lost their homes,” he says. First, he gave out money (“It was a little demeaning,” he says). Then he gave out supplies: snacks, socks, blankets in the winter, water in the summer. “After about eight years, I thought, man, I can’t figure out how to utilize my resources as a physician. I’m giving them things, and I’m being nice, but I’m not figuring this thing out.” By the time he connected with SMP in early 2021, the issue had seemed to explode. 

“[Street medicine] is growing,” he says. “Not just because of our program, but because homelessness is becoming a bigger issue, and people are realizing, especially in medical schools, that we’re not meeting the needs of the people experiencing homelessness.” Last year, he got grant funding for umbrellas to provide some relief from the heat. They wiped out the distributors. “You can’t find a store with 2,000 umbrellas.” 

According to a metric called the Point-in-Time Count, conducted by the U.S. Department of Housing and Urban Development, the number of Americans who experienced a night without a safe or stable place to sleep increased more than 35% between 2019 and 2024; in Maricopa County, it increased nearly 50%. 

Some of those people are considered “sheltered,” whether in emergency shelters or transitional housing; the rest are on the street. The unsheltered population is growing faster. Most of the sheltered will be “positively exiting” the system within a year, but plenty will slide into what is called “chronic homelessness.” Meanwhile, the homeless account for about half of the heat-related deaths in Maricopa County; that number has risen dramatically in the past decade, too. 

For Fauer, the question is how to allocate the few resources they have in ways that make the biggest impact, not just on the homeless but on the health care system that stands to bear their burden. “The person who’s going to use the most health care dollars is [already] identifying themselves by being in the hospital,” Fauer says. “And the person who is most likely to be in the hospital next experiencing homelessness is the person who’s just been discharged. Because they don’t get their follow-up, they can’t get their medicines, or their medicines have been stolen, or they can’t get their medical supplies, or they can’t make it to a follow- up appointment. Whatever it is, they’re going to get sick again.” If you could put your resources into that one person, “that’s worth tens of thousands of dollars,” Fauer says. “But we’re light years from that.” 

“What’s mind-boggling is that 80% to 90% of people experiencing homelessness are insured,” says Miller. “Very few other vulnerable populations have such robust insured numbers. I had a patient who has this humongous skin lesion that goes all around his nose and into the start of his eyes. It’s very dark black. It’s clearly a late-stage skin cancer. Realistically, he needs plastic surgery for that, or maybe some radiation, but a whole thing, because their eye orbit is there. He would need to go to a primary care doc, who would need to refer him, because with AHCCCS [the Arizona Health Care Cost Containment System, Arizona’s Medicaid], you can’t just walk into a specialist, you need to get a referral from your PCP. Even then, there are only, like, three or four dermatologists in the Valley that accept AHCCCS.” 

“I think of [SMP] as a learning opportunity,” she says. “We bribe [students] with the idea that you will see your clinical failures. 

You will see what you didn’t think of, and why people stop managing their diabetes, and all the social needs you don’t take into account at this extreme level of homelessness.” 

“The part of it I never thought of doing was teaching,” Fauer says. “Teaching the next generation of students so they understand that when someone experiencing homelessness sees them, they don’t treat them like a textbook. They’ve got think outside the book to make their medical decisions work for this person. So that’s a value, right?” 

“I tell people my job, and almost immediately — and I cannot even remember a single instance where this did not happen — they respond with something like ‘thank you’ or ‘that sounds like hard work,’ and follow it up with their own example of someone that they have seen who’s homeless,” says Miller. 

Sometimes the conversation is sympathetic, sometimes frustrated (“… all the people camping at the end of my street …”), but it always becomes personal. “It’s this underlying problem that everyone knows about,” Miller says. “But people have no idea what happens behind the scenes. They have no idea that this infrastructure exists. They see someone on the side of the highway with a sign, but they don’t see this whole industry of people. It’s hard to wrap your mind around.” 

It can be slow going. “It’s almost like my coping mechanism to talk about data and statistics, because it can be so empathetically hard,” Miller says. But beyond the challenge is the small persistent light of purpose. The day I visit Lodestar, the temperature in Phoenix hits 110 for the first time in 2025. 

The next day, it hits 114. I think of a flyer I saw taped to the inside of the SMP van’s doors, saved from a distribution event for the St. Mary’s Food Center. “LOCATION,” it says. “HERE. DATES: TODAY. TIMES: NOW.” ❖