Bringing medicine to the streets

Josh Fernelius, MD, an internal medicine specialist at Saint Louis University School of Medicine, and Margoe Chesler, RN, volunteer with Street Med STL.

Courtesy of Nathanial Nolan, MD

The ailments experienced by the people living in St. Louis' tent cities are many and varied: skin infections, frostbite, tooth abscesses, pneumonia, severe mental illness, and substance use disorders, among others.

So every Saturday a group of volunteers, made up of physicians, medical students, and other health care professionals, posts up near an encampment and offers medical care - along with food, water, and a nonjudgmental ear.

The initiative is organized by Street Med STL, a nonprofit organization founded by Nathanial Nolan, MD, an infectious disease physician at the St. Louis Veterans Affairs hospital and an associate professor at Washington University School of Medicine in St. Louis (WashU), with the help of Jay Truel, MD, and Sarah Fracasso Francis, MD, both recent graduates of WashU who started a group to help organize students interested in the health of unhoused people.

In 2024 the U.S. Department of Housing and Urban Development counted nearly 100,000 people who were sleeping out-of-doors, the highest number on record. St. Louis, a city of fewer than 300,000 residents, counted more than 660 people in 2023 who were chronically homeless, defined as experiencing homelessness for at least a year, according to the nonprofit organization Community Solutions.

As homelessness has increased, so have efforts to provide medical care to this population in more accessible ways. The Street Medicine Institute, an organization founded in 2009, has helped support programs across continents. And in the United States, as of 2023, there were about 150 organizations dedicated to street medicine, KFF Health News reported.

Getting started

Street Med STL is now made up of dozens of volunteers, but it started as an effort of one.

Nolan first began bringing his practice to the streets as an infectious disease fellow in 2020, when unhoused people were acutely impacted by the COVID-19 pandemic.

He'd been working with homeless shelters on infection prevention protocols when someone invited him to meet the unsheltered homeless, those staying in a local encampment.

"I thought I was going to tell all these people about COVID, how to protect themselves, tell them about risk reduction," Nolan says. "They had zero interest in COVID. They had other concerns, like taking care of wounds. I'd made a presumption about what people needed. At that point, I pivoted."

Nolan put together a backpack of medical supplies and spent a lot of time just listening to the people he encountered.

After he spent about two years doing outreach on his own, Nolan allowed Truel, who was then a second-year medical student, and Joey Krambs, an MD-PhD student, to shadow him.

"Bringing on students was the first step toward creating something that was more scalable," Nolan says.

As the volunteer base grew, so did the outreach efforts.

Last year, the group treated 300 unique patients across five encampments, providing 700 medical-care encounters. That includes distributing more than 2,000 doses of Naloxone, the opioid-overdose reversal drug; more than 100 prescriptions for antibiotics; and more than two dozen prescriptions for medications to help treat substance use disorders.

While Saturdays remain the biggest outreach day, volunteers also go out every day except Friday and Sunday.

"We started by just showing up without expectations and judgment," Nolan says. "Over the years, people realized that they can rely on us. Now we have people line up and wait for us."

Learning from those with lived experience

Truel, who majored in anthropology at WashU before deciding to pursue medicine, had long been interested in the human condition. In college he volunteered at a food bank and also helped out with an organization that taught youth in the foster care system about sexual health and how to guard against sex trafficking.

The experience was sometimes humbling for Truel, as he realized, despite his education, training, and good intentions, that young people's lived experiences often made them the experts in the issues they faced in a way he couldn't be.

"I'm happy I had that experience early on," he says. That humility helped him build mutual respect with the people he'd later serve on the streets of St. Louis.

That sense of humility is key to street medicine, Nolan says.

"That is one of the biggest issues in health care today when delivering care to marginalized communities. It's very frequent that the goals of health care organizations differ from those of the patients they're trying to reach," he says. "That was a good lesson for me. One of the things I realized is half the battle is just showing up and listening."

Starting Street Med STL also involved a lot of unglamorous work, such as navigating paperwork and bureaucracy, carrying supplies, and sometimes spending time on hold with pharmacies coordinating medication issues for patients.

"Students want to go into this space to do the sexy things," Nolan says. "They want to be doing the exams, the procedures, everything that they think a doctor is. But a lot of what we do is not that exciting. The mundane things we do matter a lot."

Nolan sees these encounters on the street and in encampments as ripe educational moments for students like Truel.

"There's a hidden curriculum around patients who are unhoused or have housing instability," Nolan says. "The practice of street medicine allows trainees the opportunity to really understand the lived experience of homeless patients. When you're doing street medicine, you're not sitting there having a patient's chart open in an exam room. It's a tremendous opportunity, because it really contextualizes patients who otherwise are stigmatized."

Nolan was happy to see Truel and other students develop trusting relationships with the patients.

One example of a patient who had substance use disorder stands out to Truel.

"Within that ebbing and flowing of addiction, sometimes we'd see them and they'd be doing really well and sometimes not really well," Truel recalls. After two years of consistent communication, Truel got the patient into a medication-assisted treatment program and was ultimately able to help them get into stable housing.

"That was a notable victory," Truel says. "And a big lesson in playing the long game and letting people come to you."

In perpetuity

From those first days of providing care at encampments during the pandemic, it was clear to Nolan that, if progress was to be made, it would require commitment and consistency.

While Nolan, Truel, Krambs, and Fracasso Francis made showing up at least every Saturday a priority, the students knew that matching into residency would likely mean their time volunteering in this capacity would be limited.

For this and other reasons, including raising funds for supplies and medical care, Nolan set out to make Street Med STL an official nonprofit organization. To aid the effort, Krambs, Fracasso Francis, and Truel formed a group at WashU that focused on educating students around homeless health care, with the goal of recruiting new volunteers to the mission.

Truel found no shortage of passionate and committed volunteers among his fellow students.

"The volunteer corps we developed was easy," he says. "People were so excited and willing and wanting to do something like this."

Truel organized lectures and training for the student volunteers to help develop their sensitivity to and awareness of the distinct needs of unhoused people.

Because Street Med STL now has two staff members and a robust volunteer network of dozens, when Truel left St. Louis to start his internship year in San Diego this past summer before heading to New York-Presbyterian hospital at Columbia University for his dermatology residency next year, he didn't worry about his absence creating a gap in care.

"The vision we saw was for this to be something that exists in perpetuity. I knew residency would take me elsewhere," Truel says. "We never wanted to build relationships and just leave people wondering where we are."

Nolan says that those relationships the students formed with their unhoused patients are strong and mutual. Patients ask after the graduated students, wondering how their board exams and residencies are going.

"It was incredible to see what happened when students entered that space, and seeing their own development," Nolan says. "It made me proud to see them lean into this space, where not a lot of people go."

While Nolan continues to lead the efforts in St. Louis, Truel is already thinking about how he can continue his involvement in street medicine. He sees a particular need for dermatologists in these efforts, as unhoused people experience a variety of skin conditions that are exacerbated because of unhygienic conditions.

He hopes to conduct research on this topic and, eventually, start a dermatology clinic for unhoused people, drawing inspiration from the leap Nolan took several years ago, launching Street Med STL.

"I would love to say that we are breaking ground in everything that we're doing in St. Louis, but it's built on the backs of tons of people who are doing this internationally," Nolan says.

When he was first considering creating the nonprofit, Nolan reached out to Jim O'Connell, MD, an assistant professor of medicine at Harvard Medical School and president of Boston Health Care for the Homeless Program, for advice on how to get Street Med STL off the ground.

"His advice was to just start, [that] if you wait for everything to be perfect, for all the administrators to give you the go-ahead, for all the funding you might need, you're going to be waiting forever," Nolan recalls.

It's the advice he echoes now to others hoping to start similar initiatives. "It doesn't have to be perfect. Almost anything is better than what people are receiving right now."